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SWRCB , January 2002 Page _ l _ of _7_ <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 (f 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 : 01 /16/18 <br /> Facility Address : 1524 Fresno Ave. , Stockton , CA 95206 <br /> Facility Contact: Mike Eliason Phone : (209) 993-$793 <br /> Date Local Agency Was Notified of Testing : 01 /04/18 via email <br /> Name of Local Agency Inspector (ifpresent during testing) : Betty Ho @ San Joaquin E . H . D . <br /> 2 . TESTING CONTRACTOR INFORMATION <br /> Company Name : CGRS , Inc . <br /> Technician Conducting Test: Richard Thomas <br /> Credentials : M CSLB Licensed Contractor M SWRCB Licensed Tank Tester <br /> License Type : C61ID40ID64 803616 (CSLB Lie .) License Number: 803616 (CSLB Lie.) 06 -1672 (SWRCB Lie.) <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> ICC CA UST SERVICE TECHNICIAN : #5254736 11 /17/2018 <br /> ICC UST TANK TIGHTNESS TESTING : #5254736 03/08/2018 <br /> SCWRCB TANK TESTER LICENSE : #06 -1672 06/30/2018 <br /> FRANKLIN FUELING INCON SUMP TESTER : #1001773708 02/06/2019 <br /> 3 . SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> T-1 Diesel Tank Annular M ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> T=1 Diesel Product Line #1 M ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> T-1 Diesel Product Line #2 ® ❑ ❑ 1 ❑ ❑ I ❑ ❑ 1 ❑ <br /> TA Diesel STP Sump M ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> UDC #1 -2 M ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> UDC#1 Satellite M ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> UDC#2 Satellite 1 #3 Satellite M ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> UDC#34 M ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ El <br /> El El El ❑d[E ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed , describe what was done with the water after completion of tests : <br /> TECHNICIAN CARRIES A 535 GALLON TANK FOR TESTING WATER <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge, the facts stated in this document are accurate and in full compliance with legal requirements <br /> Technician ' s Signature: " Date : 01 /16/18 <br />