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SWRCB, January 2002 Page I of� Secondary Containment Testing Report Form This form is intendedfor use by contractors performingperiodic testing of UST secondary containment systems. Use the appropriate pages of this form to report results for all components tested The completed form, written test procedures, and printouts from tests (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. 1. FACILITY INFORMATION Facility Name: Valley Pacific Petroleum Date of Testing: 4-8-16 Facility Address: 1524 Fresno Ave., Stockton, CA Facility Contact; Mike Eliason Phone: Date Local Agency Was Notified of Testing: 4-6-16 Name of Local Agency Inspector (rfpresent during testing): Stacie Rivera 2. TESTING CONTRACTOR INFORMATION Company Name: Kem County Construction, Inc. Pass Technician Conducting Test: Josh Simmons Not Tested Credentials: x CSLB Licensed Contractor D SWRCB Licensed Tank Tester License Type: A, B, Haz License Number:481053 Manufacturer Training Manufacturer Component(s) r NDate Trainin Es fres Incon TS -STS UDC 1/2 X ❑ _- APR 15 Z016 ❑ ❑ 3. SUMMARY OF TEST RESULTS`'Tac'n�+hr Component p Pass Fail Not Tested Repairs Made Component Pass Fail Not Tested Repairs Made UDC 1/2 X ❑ ❑ ❑ ❑ 0 ❑ ❑ UDC 3/4 X 0 D ❑ 0 ❑ ❑ 0 UDC 1 Satellite X 0 0 D D D 0 ❑ UDC 2-3 Satellite X ❑ ❑ ❑ 0 0 0 ❑ #1 Satellite Secondary X D 0 ❑ _ - 0 0 0 0 #2 Satellite Secondary X ❑ D ❑ ❑ ❑ 0 ❑ #3 Satellite Secondary X ❑ ❑ ❑ 0 0 0 ❑ 1-2 Secondary X ❑ D ❑ ❑ 0 ❑ ❑ 0 ❑ 0 0 0 0 D ❑ ❑ D ❑ 0 _ 0 0 0 ❑ D ❑ ❑ I ❑ 0 0 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ If hydrostatic testing was performed, describe what was done with the water after completion of tests: Water returned to test tank for re -use. CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING To the best of my knowledge, the facts stated in this document are accurate and in full compliance with legal requirements r Technician's Signature: Date: 4-8-16