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SW RCB,January 2002 Page_—of <br /> Secondary Containment Testing Report Form <br /> Thu form is intendedfor use by comrociors performing periodic testing of UST secondan'containment.patems. Use the <br /> appropriate pages of thu form to report resulu for all components tested. The completed form,written test procedures,and <br /> printau[s from rests flfapplicable),should be provided to the facility ownerloperatorfor submittal to the local regulatory agency - <br /> 1. FACILITY INFORMATION <br /> Facility Name: Valley Pacific Petroleum Date of Testing: 11-14-16 <br /> Facility Address: 930 E Victor Rd- <br /> facility <br /> dFacility Contact: Mike Eliason Phone: <br /> Date Local Agency Was Notified of Testing: 11.12-16 <br /> Name of Local Agrncy Inspector(Jfprasent during testing): <br /> 2" TESTING CONTRACTOR INFORMATION <br /> Company Name: Kent County Construction,Inc. <br /> Technician Conducting TM: Josh Simmons <br /> Credentials: x CSLB Licensed Contractor _SWRCB Licensed Tank Tester <br /> License Type: A,B,Haz License Number.481053 <br /> Manufacturer Training <br /> Manufacturer Com oreent(s) Date Training Expires <br /> 3" SUMMARY OF TEST RESULTS <br /> Component Pau Frit Not Repair, Component Pass Fail Not Repairs <br /> rated Made Tested Made <br /> 87 South Secondary X = - ❑ _ <br /> 87 North Secondary X _ - - 7 - - <br /> J <br /> n f-/ L <br /> El C <br /> _ C <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> Water renuned to tank for reuse. <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the bat ofmy knowledge,thefocd sorted this document am accurate and in full compliance wihi legal requireme is <br /> 'Technician's Signature: Date:_II"I4-16 <br />