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Page 1 of 14 ONW& <br /> Secondary Containment Testing Report Form <br /> This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the appropriate pages of <br /> this form to report results for all components tested. The completed form,written test procedures,and printouts from tests(if applicable),should <br /> be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Tracy Truck Stop Date of Testing: 1/16/2009 <br /> Facility Address: 3940 N. Tracy Blvd. Tracy, CA 95304 <br /> Facility Contact: Debbie I Phone: 209-832-5006 <br /> Date Local Agency Was Notified of Testing: 01/14/2009 <br /> Name of Local Agency Inspector(if present during testing): N/A <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: EPIC Compliance Systems <br /> Technician Conducting Test: Keith Huston <br /> Credentials: 0 CSLB Licensed Contractor SWRCB Licensed Tank Tester <br /> License Type: A License Number:880430 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> Caldwell Caldwell Level Indicator N/A <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> Annular 1 a] Ll Ll 0 Sump 5 0 J Ll J <br /> Annular 2 21 Ll Lml LJ Sump 6 L3 J o J <br /> Annular 3 0 J zi L) UDC 1-2 0 Ll Ll Ll <br /> Sec Pipe 1 0 Ll U Ll UDC 3-4 21 Ll Ll Ll <br /> Sec Pipe 2 0 Ll Ll Ll UDC 5-6 0 L3 Ll Ll <br /> Sec Pipe 3 0 Li Lj J UDC 7-8 0 L:l J L3 <br /> Sec Pipe 4 [R] Ll L3 Ll UDC 9-10 0 Lj Ll Lj <br /> Sec Pipe 5 0 Lj Lj U UDC 11s El U J J <br /> Sump 1 0 L) L3 Ll UDC 11-12a o Ll L3 J <br /> Sump 2 0 El Ll Lj UDC 12-13a FKI Ll Li Lj <br /> Sump 3 L3 0 Ll Ll UDC 13-14a El Ll Lj Lj <br /> Sump 4 Ell Ll I J I Ll UDC 14-15a 0 Lj L, <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> Filtered back into 500 gal water trailer. <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,the facts stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: Date: 1/16/09 <br />