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e <br /> Secondary Containment Testing RepoRfiQE V <br /> For Use by Unidocr MemberAgencies or where approved by your Local Jurisdiction <br /> AuthorityCited: Health and Safety Code§25293;Title 23 CCR§2637(a)(4) V1 AY i 2 2017. <br /> This form, or the standard form deveiped by the State Water Resources Control Bo x hJJJt1b - T <br /> by contractors performing periodic testing of underground storage tank (UST) secondary -' Tems <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 f©r 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 suinp/UDC is not equipped with a continuous monitoring system that shuts down the pump when a leak is <br /> deteeetd or the leak detection sensor fails or is disconnected. [see SNVRCB Local Guidance Letter LO-1601 <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, my 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: 1.700 E.Yosemite Ave. Manteca, CA. <br /> Facility Contact: Sunny Phone: 408-230-8999 <br /> Date Local Agency was Notified of Testing: 5/2/2017 <br /> Name of Local Agency Inspector(if present during testing): <br /> B. Testing Contractor Information <br /> Company Naine: Donlee Pump Company <br /> Credentials: ' ❑CSLB-Licensed Contractor; ❑SWRCB-Licensed Tank Tester <br /> License Type: C3 A;❑C-lo;❑C-34;❑C-36;❑C-61 (D4(}) =License Number: B43182 <br /> Name of Technician Conducting Tests: Anthony Leivas <br /> Training by Equipment Manufacturer <br /> Manufacturer Component(s) Date Training Expires <br /> ]Franklin Fueling Incon Lev14 . 7529843707 11/11/17 <br /> C. Certification by Technician Responsible for Conducting Testing <br /> To the best of my katowledge,the facts st ted in this document are accurate and in full compliance with <br /> legal requirements. <br /> Technician's Signature: Date: 5-S- 1 7" <br /> UN-054-1/5 rrwtv.unidocs.org 02/26/02 <br />