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Secondary Containment Testing Report Form For Use by Unidocs Member Agencies or where approved by your Local Jurisdiction Authority Cited., Health and Safety Cade §25293; Title 23 CCR §2637(a)(4) This form, or the standard form develped by the State Water Resources Control Board (SWRCB), trust be used by contractors performing periodic testing of underground storage tank (UST) secondary containment systems in Unidocs member agency jurisdictions. The completed form, written test procedures, data collection logs, and printouts from test equipment (if applicable), must be provided to the facility owner/operator for submittal to the local regulatory agency within 30 days of the test date. SWRCB requires that the entire volume of each sump and under -dispenser containment (UDC) system be tested if the sump/UDC is not equipped with a continuous monitoring system that shuts down the pump when a leak is detecetd or the leak detection sensor fails or is disconnected. [see SWRCB Local Guidance Letter LG -1641 Systems where leak detection equipment continuously monitors both primary and secondary containment (e.g. systems that are hydrostatically monitored or under constant vacuum) are exempt from periodic testing requirements. [23 CCR §2637(a)(6)1 In the case of pressure/vacuum testing, any loss in pressure/vacuum during the course of the test shall be considered a failed test, regardless of the manufacturer's criteria for declaring a passed test. [23 CCR §2637(a)(2)1 A. Facility Information Facility Nam 1: Vallev Pacific Petroleum Services Date ai'Testing: January 10, 2012 -��- Site Address: 1524 Fresno Ave., Stockton, CA _ Facility Contact: _ Mike Eliason Phone: 800-266-3782 Date Local Agency was Notified of Testing: 1-3-12_,__ Name of Local Agency Inspector (if *present during testing): B. Testing Contractor Information Company Name: Kern C:oun Construction, Inc. Credentials: ® CSLB-Licensed Contractor; ❑ SWRCB-Licensed Tank Tester License Type: ® A; ❑ C-10; ❑ C-34; ❑ C-36: ❑ C-61 (1340) License Number: 481.053 Name of Technician Conducting Tests: Josh Simmons Training by Equipment Manufacturer Manufacturer Component(s) Date Training Expires Incon TS -STS 12-2-12 C. Certification by Technician Responsible for Conducting Testing To the best of my knowledge, the facts tated in this document are accurate and in full compliance with legal requirements. Technician's Signature: Date: _i._"' - 1 ITN -054 -1/5 www.unidecss.org 42/26!!12