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Page of <br />SWRCB, January 2002 <br />Secondary Containment Testing Report Form <br />Thisform is intendedfor use by contractors performing periodic testing of UST secondary containment systems. Use the <br />appropriate papas of this form to report results,for all components tevteti The completed farm, written test procedures, and <br />printouts from tests (rf applicable), should be provided to thefacility owner/operator,for submittal to the local regulatory agency. <br />1. FACXLM INFORMATION <br />Date of Testing: I0-17-12 <br />Facility Name: Valley Pacific Petroleum <br />Facility Address: 1.524 Fresno Ave., Stockton, CA <br />Facility Contact: Mike F..liason Phone. <br />Date Local Agency Was notified of Testing: 10-10-12 <br />Rivera <br />Name of Local Agency Inspector {if present during testing): Stacie . <br />2. TESTING (:01NJ- A ;1 UR 1 PI r V-M'.Yita x a.vi. <br />Company Name: ICern County Construction, Inc_ <br />Technician Conducting Test: Josh Simmons <br />Credentials: x CCSL B Licensed Contractor C i SWRCB Licensed Tank Tester <br />License Type, A, 8, Haz License Number:481053 <br />Manufacturer Training <br />3. <br />SUMMARY <br />OF <br />TEST <br />RESULTS <br />Component <br />)PASS <br />Foal <br />Not <br />Tested <br />Re nirs <br />Made <br />Component <br />I'flAR <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />CmC 1/2 <br />x <br />❑ <br />❑ <br />u <br />❑ <br />❑ <br />❑ <br />❑ <br />LI <br />❑ <br />❑ <br />n <br />❑ <br />❑ <br />r� <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />i.:� <br />❑ <br />❑ <br />❑ <br />❑ <br />I� <br />❑ <br />M <br />C_l <br />❑ <br />❑ <br />❑ <br />❑ <br />(l <br />❑ <br />I-1 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Ll <br />❑ <br />❑ <br />r� <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />1-J <br />❑ <br />0 <br />0 <br />❑ <br />❑ <br />❑ <br />❑ <br />If hydrost,'itie testing was performed, describe <br />what <br />was done <br />with <br />the water atter completion of tests: <br />Water returned to test tank for Ire <br />-use. <br />CERTIFICATION OF TVC;HNICIAN RESPONSIuLF, FOR CONDUCTING T14TS TIESTTN(,, <br />To tl:e hest of rrty knowledge, tltefadts stated in rh.is docuwnt are accurate and in full compliance Willi legal requirements <br />Date:10-17-12 <br />Technician's Signature:.,._ � <br />