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Y. IR <br /> 0 <br /> SWRCB,January 2002 Page_L_of 3 <br /> Secondary Containment Testing Report Form <br /> ;Phis form is intended for use by contractors performing periodic testing of ST secondary containment systems. Ilse the <br /> appropriate pages of this form to report results for all components tested The completed form, written test procedures, and <br /> printouts from tests(if applicable),should be provided to the facility owner)'operatorfor submittal to the local regulatory agency. <br /> 1. FACILITY INFOTI N <br /> ; -F—Date of Testing: 2-4-16 <br /> Facility Name: Valley Pacific Petroleum <br /> Facility Address: I501 Charter Way,Stockton,CA <br /> -Facility Contact: Mike Eliason Phone: <br /> Date Local Agency Was Notified of Testing: 1-26-16 <br /> loom Ww <br /> Name of Local Agency Inspector(tfpresent during testing)- I <br /> 2, TESTING CONTRACTOR INFO TION MAR 112016 <br /> Company Name; Kern County Construction,Inc. <br /> EL_ IV 11HRWRIEMENTAIL <br /> Technician Conducting Test:— Josh Simmons EAl NT <br /> Credentials: x CSLB Licensed Contractor D SWRCB Licensed Tank Tester <br /> License Type: A,B,Haz License Number:481053 <br /> Manufacturer Trai lag <br /> Manufacturer Com ponent(s) Date Training Expires <br /> -INCON TS-STS 10-11-17 <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Repairs Not Repairs <br /> Component Pass Fail Tested Made Component Pass Fail Tested Made <br /> UDC 1-2 X El El El ❑ 0 0 0 <br /> 87 Secondary X 11 El 0 ❑ 0 0 0 <br /> 0 0 <br /> El 0 El 0 ❑ 0 El 0 <br /> ❑ 0 0 0 <br /> 0 0 n 0 <br /> n 0 El [I <br /> 0 1 11 0 0 0 0 El 11 <br /> n 0 El El <br /> El ❑ ❑ El <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> Water retumed to test twk for re-use. <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE F ?R CONDUCTING THIS TESTING <br /> To the best of my knowledge,the facts s d in this document are accurT and in full compliance with legal requirements <br /> Technician's Signature:7:_2, = Date: 24-16 <br />