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May.' 9. 2017 4: 11PM Donlee Pump Co U. 723a :P, <<.2 <br /> Secondary Containment Testing Report Form , .; <br /> For Use by Unidocs iMemberAgencies or-where approved by your Local Jurisdiction <br /> Authority Cited.• Health and Safety Code§25293;Title 23 CCR§2637(a)(4) <br /> This form, or the standard form develped by the State Water Resources Control Board (SWRCB), must be used <br /> by contractors performing periodic testing of underground storage tank (UST) secondary containment systems <br /> in Undoes member agency jurisdictions. The completed form, written test procedures, data collection logs, and <br /> printouts from test equipment (if applicable), must be provided.to the facility owner/operator for submittal'to <br /> the local regulatory agency within 30 days of the test date. <br /> SWRCB requires that the entire volume of each sump and under-dispenser containment(UDC)system be tested <br /> if the sump/UDC is not equipped with a continuous monitoring system that shuts down the pump when a leak is <br /> detecetd or the leak detection sensor fails or is disconnected. (so swpca Local Guidance Letter La-160] <br /> Systems where leak detection equipment continuously monitors both primary and secondary containment (e.g. <br /> systems that are hydrostatically monitored or under constant vacuum) are exempt from periodic testing <br /> requirements. [23 CCR§2637(x)(6)] <br /> In the case of pressure/vacuum testing, iy loss in pressure/vacuum during the course of the test shall be <br /> considered a failed test,regardless of the manufacturer's criteria for declaring a passed test. (23 CCR§2637(x)(2)] <br /> A. Facility Information <br /> Facility Name: Statewide Petroleum Date of Testing: May 9,2017 <br /> Site Address: 1700 E. Yosemite Ave. Manteca,CA. <br /> Facility Contact: Sunny phone: 408-230-8999 <br /> bate Local Agency was Notified of Testin : 5/2/2017 <br /> Name of Local Agency Inspector(ffpresent daring testing): <br /> B. Testing Contractor information <br /> Company Dame: YDonlee Pump Com an <br /> Credentials: ❑CSLB-Licensed Contractor; ❑SWRCB-Licensed Tank Tester <br /> License Type: 0 A,Q C-10;❑C-34;❑C-36;❑C-61 (D40) License Number: 8431$2 <br /> Name of Technician Conducting Tests: Anthan Leivas <br /> Trainin b 1J ui ment Manu£actu rer <br /> Manufacturer Component($) nate Training Expires <br /> Franklin Fueling Incon Levl 4 7529843707 11/11/17 <br /> C. Certification by Technician Responsible for Conducting Testing <br /> To the best of my knowledge,the facts st ted in this document are accurate and in full compliance with, <br /> legal requirements. <br /> a <br /> Technician's Signature: Date: <br /> UN-051-115 mmunidocs,org 02rAM <br />