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03/22/2012 a7: 31 0000000000 PAGE 01/07 <br />Secondary Containment Testing Report Form <br />For Use by Unidocs 1ember Agencies or where approved by ynur Local Jurisdictiotl <br />Authority Cited., Health and Safety Code ,$25293; Title 23 CCR §2637(4)(4) <br />This fotm, or the standard foram develped by the State Water ResourcesWRCB), must be used <br />by contractors performing periodic testing of underground storage tank (UST) naiy`:c,�t`vubmittal. <br />t systems <br />in Unidocs member agency. jurisdictions. Tile completedl�orm., ,written test pr cedures', data. t 1logs, acid <br />printouts from test equipment (if applicable), trust be provided to the facile r erator,to <br />the local. regulatory agency within. 30 days of the test date, <br />S WRCB requires that the entire volume of each sump and under-dispensebC <br />„ �t ) system be tested <br />if the stump/UDC is not equipped with a continuous monitoring system that shuts drs4eOe pump when a leak is <br />detecetd or the leak detection. sensor . ils or is discozxrrected. [see sWRcr3 r,00al outdone Lcuer Lc.r 601 <br />Systems where leak. detection equipment continuously monitors both primary and secondary containment (e.g. <br />systems that arc hydrostatically monitored or under constant vacuuru) are exempt from periodic testing <br />requiremei1ts. [23 CCR §2637(a)(6)I <br />Tn the case of pressure/vacuum. testing, M loss in pressure/vacuum during the course of the test shall be <br />considered a failed test, regardless of the manufacturer's criteria for declaring a passed test. [23 CCR §2637(a)(2)] <br />A. Facility Information <br />Facility Name: Valley Pacific Petroleums Services Date of Testing: Janus 10, 20.12 <br />Site Address: 1.524 Fresno Ave., Stockton, CA <br />Facility Contact: Mike Eliason Phone: 800-266-3732 <br />Date Local A,geney Navas Notified of Testing : 1-3-12 <br />Name of Local Agency inspector (fpresctlt dieting testin,n,): '- <br />B. Testing Contractor Information <br />Company Name: Vern County Construction, Inc. <br />Credentials: ® CSLT3-Licensed Contractor; ❑ SWRCB-Licensed Tank Tester <br />License Type: ® A; 0 C-10; F] C-34; [J C-36; ❑ C-61 (D40) License Number: 451053 <br />Name of Technician Conducting Tests: Josh Simpsons <br />Trainin b E ui ment Manufacturer <br />_g- y q <br />Nlianufaett,rer Component(;s) Date Training .Expires <br />fucon <br />TS -STS <br />12-2-12 <br />C. Certification by Technician Responsible for Conducting Testing <br />To the best of my knowledge, the facts stated in this document are accurate and in fill] compliance with <br />legal requirements. <br />Technician's Signotur•e; � _ Date: <br />UN -054 - US �. ti� w.unidoca.nrg 02126/02 <br />