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SWRCB, January 2002 Page 1 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 thisform 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: 4-8-16 <br />Facility Address: 1524 Fresno Ave., Stockton, CA <br />Facility Contact: Mike Eliason Phone: <br />Date Local Agency Was Notified of Testing: 4-6-16 <br />Name of Local Agency Inspector (rfpresent during testing): Stacie Rivera <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, Haz License Number:481053 <br />Manufacturer Training <br />Manufacturer Component(s)Date TrainingExpires <br />Incon TS -STS 2-8-16 <br />3. SUMMARY OF TF,ST RF.RITI.TC <br />Com onent <br />P <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made Component <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />UDC 1/2 <br />X <br />❑ <br />1 ❑ <br />❑ <br />❑ <br />❑ <br />[I <br />❑ <br />UDC 3/4 <br />X <br />❑ <br />❑ <br />El❑ <br />0 <br />[I <br />[IUDC <br />1 Satellite <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />UDC 2-3 Satellite <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />#1 Satellite Secondary <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />#2 Satellite Secondary <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />#3 Satellite Secondary <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />1-2 Secondary <br />X <br />❑ <br />❑ 1 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />water retumea to test tank for re -use. <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: 4-8-16 <br />