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Secondary Containment Testing Report Form <br /> This form is intendedfor use by contractorsperformingperiodic resting of USTsecondary containment systems. Usethe <br /> appropriate pageg of this form to report results for all components tested. The completed form, written test procedures, and <br /> printoutsfrom tests(if applicable),should be provided to thefacility owner/operutor for submittal to the local regulatory agency. <br /> I. FACILITY INFORMATION <br /> Facility Name: VANCO TRUCK PLAZA Date of Testing' 813201.6 <br /> facility Address., 1033 W.CRARTER WAY,STOCKTON County SAN JOAQUIN <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing: <br /> Nance of Local Agency Inspector(#-present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: B.Z.Service Station Maintenance <br /> Technician Conducting Test: DAVID ROUSE <br /> Credentials: ®CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester <br /> License Type: ICC License Number.433159 <br /> M_ artufacturcr Traigine <br /> Manufacturer Component(s) Date TrainjEg Expires <br /> INCON TS-STS <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> OCT. 100 UDC 12-13 SAT <br /> 87 VENT SEC UDC 13-14 M El Ell 0 <br /> 91 VENT SEC UDC 14 SAT <br /> DSL 1 VENT SEC Lil UDC 8-9 SAT <br /> DSL 2 VENT SEC UDC 9-10 <br /> UDC 1-2 UDC 10 SAT <br /> UDC 3-4 UDC 15-16 <br /> 97 SAT TZT7 El <br /> UDC 7-8 <br /> UDC 5-5 <br /> UDC 11 SAT <br /> UDC 11-12 El I <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> TOOK AS TEST WATER <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my Itnowledge,the facts stated In this document are accurate and in full compliance with legal requirements <br /> Technician's Siguature:_ t C!/ Date:$#3/2016 <br /> Secondary Containment Test Results I of is <br /> ?9 l2 Z3z3sa <br />