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SWRCB, January 2002 Page I of <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 I Date of Testing: 11-15-16 <br />Facility Address: 1524 Fresno Ave., Stockton, CA <br />Facility Contact: Mike Eliason Phone: <br />Date Local Agency Was Notified of Testing : 11-12-16 <br />Name of Local Agency Inspector (tfpresent during testing): <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: Kern County Construction, Inc. <br />Technician Conducting Test: Josh Simmons <br />Credentials: x CSLB Licensed Contractor SWRCB Licensed Tank Tester <br />License Type: A. B. I-laz License Number:481053 <br />Manufacturer Training <br />Manufacturer Component(s) Date Training Expires <br />Incon TS -STS 11/1/16 <br />3. SUMMARY OF TEST RESULTS <br />Component <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />Component <br />Pass <br />lot Repairs <br />Fail Tested I Made <br />UDC Satellite 1 <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ ❑ ❑ <br />UDC Satellite 2/3 <br />X <br />❑ <br />❑ <br />❑ <br />0 <br />0 0 ❑ <br />0 <br />0 <br />0 <br />❑ <br />❑ <br />❑ ❑ ❑ <br />#1 Satellite Secondary <br />X <br />❑ <br />❑ <br />❑ <br />1 <br />❑ <br />0 ❑ 0 <br />#2 Satellite Secondary <br />X <br />1 <br />0 <br />0 <br />0 <br />0 0 0 <br />#3 Satellite Secondary <br />X <br />❑ <br />0 <br />0 <br />0 0 0 <br />0 <br />❑ <br />❑ <br />❑ <br />0 <br />0 0 ❑ <br />0 <br />0 <br />11 <br />0 <br />❑ <br />0 0 ❑ <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 0 0 <br />0 <br />0 <br />❑ <br />0 <br />0 <br />0 ❑ 0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 0 0 <br />0 <br />❑ <br />r- <br />❑ <br />0 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 s ted this document are accurate and in full compliance with legal requirements <br />Technician's Signature: Date: 1 1-1 ;-16 <br />