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"i ''� P.O. Box 4208 <br />it <br />"�' � � +� Sonora CA 95370 <br />hp <br />et <br />�L 1:,0i r . D Ca: 623541 A-Haz <br />AeC <br />Phone: 209-532-7320 <br />Compliance without Compromise MAR v U 2012 Fax: 209-533-2650 <br />Jr�F,G:i11PJ I�QI_iP,lr[ mail@alltechpetro.com <br />/EP www.alltechpetro.com <br />Secondary Containment Testingg'Report Form <br />This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the appropriate pages of this <br />form to report results for all components tested. The completed form, written test procedures, and printouts from tests (if applicable), should be <br />provided to the facility owneo'operator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: Village West Marina I Date of 3/21/12 <br />Facility Address: 6649 Embarcadero Drive Stockton CA 95217 <br />Facility Contact: Mike Spence Phone: 209-951-1551 <br />Date Local Agency Was Notified of Testing <br />Name of Local Agency Inspector (if present during testing): Garrett Backus <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: Alltech Petro Inc. <br />Technician Conducting Test: Isaac Anderson <br />Credentials: ® CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester <br />License Type: A-Haz License Number: 623541 <br />Manufacturer Training <br />Manufacturer Component(s) Date Training Expires <br />Caldwell Sump Tester 4-13-13 <br />3. SUMMARY OF TEST RESULTS <br />Component <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Component <br />Made <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />91 Turbine Sump <br />® <br />❑ <br />❑ <br />❑ 91 Fill Bcket <br />® <br />❑ <br />❑ <br />❑ <br />Red Diesel Turbine Sump <br />Z. <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Transition Sum <br />® <br />❑ <br />II <br />❑ I Red DSL Fill Bucket <br />® <br />I ❑ <br />I ❑ <br />❑ <br />UDC 1 <br />® <br />I ❑ <br />1 ❑ <br />1 ❑ I <br />❑ <br />❑ <br />❑ <br />❑ <br />UDC 2 <br />® <br />I❑ <br />❑ <br />1 ❑ 1 87 Annular <br />® <br />1 ❑ <br />❑ <br />❑ <br />UDC 3 <br />❑ <br />❑ <br />❑ <br />❑ Red DSL Annular <br />® <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />91 Product Line to transition <br />® <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Red Diesel Product Line to <br />transition <br />® <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />91 Product Line to dispensers <br />® <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Red Diesel Product Line to <br />dispensers <br />® <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />If hydrostatic testing was performed, describe what was done with the water after <br />completion of tests: <br />Testina water stored in barrels onsite <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: 4/30/09 <br />