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03118/2015 02:13PM 6616349233 KERN CONSTRUCTION PAGE 14127 <br /> SWRCB,January 2002 Page f of 16 <br /> Secondary Containment Testing Report Form <br /> This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use 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/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Valley Pacific Petroleum Date of Testing: 3-17-15 <br /> Facility Address: 1501 Charter Way;Stockton,CA <br /> Facility Contact: Mike Ehason Phone: <br /> Date Local Agency Was Notified of Testing: 3-12-15 F <br /> Act <br /> Name of Local Agency Inspector(f present during testing): L1 tl <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Kern County Construction,Inc. mr-III JL U U15 <br /> Technician Conducting Test: Josh Simmons ENWROWRAE-NI TAU <br /> Credentials: x CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester '?a Miro4"aea,T <br /> License Type: A,B,Haz License Number:481053 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> WCON TS-STS 10-11-15 <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Repairs Not Repairs <br /> Component Pass Fail Tested Made Component Pass Fail Tested Made <br /> DSL Annular X ❑ ❑ ❑ ❑ 0 ❑ ❑ <br /> 87 Annular X ❑ ❑ ❑ ❑ 0 ❑ ❑ <br /> 87 Secondary ❑ 1 X 1 ❑ ❑ ❑ ❑ ❑ 1 ❑ <br /> DSL Secondary X ❑ ❑ ❑ ❑ 0 ❑ ❑ <br /> 87 STP X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> DSL STP X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> UDC 1-2 ❑ ❑ X ❑ ❑ ❑ ❑ ❑ <br /> LjDC 3-4 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> UDC 5-6 Satellite X 0 0 ❑ ❑ ❑ 0 ❑ <br /> UDC 6-7 X ❑ ❑ ❑ ❑ ❑ D ❑ <br /> UDC 7 Satellite X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ D ❑ ❑ ❑ 0 ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> Water returned to test tank for re-use. <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,the facts st in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: Date: 3-16-15 <br /> Received Time Mar. l$, 2015 3: 16PM No. $366 <br />