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SWRCB, January 2002 Page I of 10 Secondary Containment Testing Report Form Thu form is intendedfor use by contractors performing periodic testing of USTsecondary containment systems. Use the appropriate pages of thisform 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 INFORMeTTrnv Facility Name: Valley Pacific Petroleum Date of Testing: 3-17-15 Facility Address: 1524 Fresno Ave., Stockton, CA Facility Contact: Mike EliasonI Phone: Date Local Agency Was Notified of Testing: 3-12-15 Name of Local Agency Inspector (rf present during testing): Stacie Rivera 2. TESTING CONTRACTOR INFORMATION Company Name: Kern County Construction, Inc. Technician Conducting Test: Josh Simmons Credentials: x CSLB Licensed Contractor ❑ SWRCB Licensed Tank Tester License Type: A. B. Haz License Number:481053 Manufacturer Training Manufacturer Com onent(s Date TrainingExpires Incon TS -STS 10-11-15 Not [Tested Repairs Made UDC 1/2 3. SUMMARY OF TEST REST TLTS Component Pass Fail Not Tested Repairs Made Component Pass Fail Not [Tested Repairs Made UDC 1/2 X ❑ 11 ❑ ❑ 0 0 UDC 3/4 X ❑ ❑ ❑ ❑ ❑ 0 ❑ UDC 1 Satellite X ❑ ❑ ❑ ❑ ❑ 0 ❑ UDC 2-3 Satellite ❑ X ❑ ❑ 11 El 0 0 DSL STP X ❑ 0 ❑ ❑ ❑ 0 0 #1 Satellite Secondary X ❑ ❑ ❑ ❑ ❑ 0 0 #2 Satellite Secondary X ❑ ❑ ❑ ❑ ❑ 0 0 #3 Satellite Secondary X ❑ ❑ ❑ ❑ ❑ 0 ❑ 1-2 Secondary X ❑ ❑ ❑ ❑ ❑ ❑ ❑ 34 Secondary X ❑ ❑ ❑ 0 ❑ 0 ❑ ❑ ❑ 0 ❑ ❑ ❑ ❑ ❑ n ❑ ❑ F ❑ ❑ ❑ 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 Technician's Signature: Date: 3-17-15