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Elite IV Contractors Page 1 of 2 <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 <br /> appropriate pages of this form to report results for all components tested. The completed form, written test procedures,and <br /> printouts front tests(if applicable), should be provided to the facility ownerloperator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name Vanco Truck and Auto Plaza Date of Testing: 9/8/2017 <br /> Facility Address: 1033 W Charter Way Stockton Ca 95206 <br /> Facility Contact: Mike Popari Phone:9 9 . 65 <br /> Date Local Agency Was Notified of Testing: <br /> -t*t( %�� <br /> Name of Local Agency Inspector(fpresent during testing): <br /> TA0249501 <br /> 2. TESTING CONTRACTOR INFORMATION SEP 18-2011 <br /> Company Name: Elite IV Contractors <br /> Technician Conducting Test:Joe Bartholdi ENVIR <br /> Credentials: X CSLB Licensed Contractor SWIICB Licensed Tank Tester <br /> License Type: ICC California UST Service Technician License Number: ICCO0042842 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> ICC 9/2018 <br /> Caldwell 412018 <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Repairs Not Repairs <br /> Component Pass Fail Tested Made Component Pass Fail Tested Made <br /> 11/12 UDC X <br /> 8/9 UDC X rn It EDa=. <br /> 9/10 UDC X <br /> 14 UDC X <br /> Diesel#2 Stamp X <br /> ROP`. <br /> DEf• -n IT <br /> If hydrostatic testing was performed,describe what was done:with the water after completion of tests: <br /> Place In Haamat <br /> CERTIFICATION OFTECHNICIAN RESPONSIBLE FOR.CONDUCTING THIS TESTING <br /> To the best of my knowledge,the f9rC stated in this data ent are accurate and in full compliance with legal requirements <br /> Technician's Signature: I / Date: 9/8/2017 <br /> ��pZ3Z3�� <br />