Laserfiche WebLink
CE1SWRCB,January 2002R E g�� — <br /> Secondary Containment Testing Report Form SAN 2 6 2018 <br /> This farm is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the <br /> appropriate pages ofthis form to report resultsfor all components tested The completedform, writtg gds L MfALTH <br /> printoutsfrom tests(ifapplicable), should be provided to the facility owner/operator for submrtw,Yh�l3'17egu a)nfency. <br /> 1. FACILITY INFORMATION <br /> uiei Fl e <br /> Facility Name: Valley Pacific Petroleum Date of Testing: 01/19/18 <br /> Facility Address: 931 East Victor Rd., Lodi,CA 95240 <br /> Facility Contact: Mike Eliason Phone: (209)993-8793 <br /> Date Local Agency Was Notified of Testing: 01/04/18 via email <br /> Name of Local Agency Inspector(ifpresent during testing): Cesar Ruvalcaba @ San Joaquin E.H.D. <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: CGRS,Inc. <br /> Technician Conducting Test: Richard Thomas <br /> Credentials: ® CSLB Licensed Contractor ® SWRCB Licensed Tank Tester <br /> License Type: C61/D40/D64 803616(CSLB Lic.) License Number- 803616(CSLB Lie.)06-1672(SWRCB Lie.) <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> ICC CA UST SERVICE TECHNICIAN: #5254736 11/17/2018 <br /> ICC UST TANK TIGHTNESS TESTING: #5254736 03/08/2018 <br /> SCWRCB TANK TESTER LICENSE: #06-1672 06/30/2018 <br /> FRANKLIN FUELING INCON SUMP TESTER: #1001773708 02/06/2019 <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> T-6 87/T-7 87 Tank Annular ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> T-6 87 Product Line ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> T-6 87 STP Sump ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> T-7 87 Product Line ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> T-7 87 STP Sump ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> UDC#1-2 ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> UDC#3-4 ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> TECHNICIAN CARRIES A 535 GALLON TANK FOR TESTING WATER <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,the facts stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: �—"-� � Date: 01/19/18 <br />