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10/10/2014 02:58PM 6616349233 <br />SWRCB, January 2002 <br />KERN CONSTRUCTION <br />RF'^,EIV.ED <br />. OCT 10 '2014 <br />PAGE 01105 <br />Page ( of -4— <br />Secondary Containment Testing ReXort lFor,RtIaEALTH <br />This form is intended for use by contractors performing periodic testing of UST secon <br />�'0k 6mems. 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 (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Date of Testing: 9-24-14 <br />Facility Name: Valley Pacific Petroleum <br />Facility Address, 1524 Fresno Ave., Stockton, CA <br />Facility Contact: Mike Eliason Phone: <br />Date Local Agency Was Notified of Testing: <br />9-22-14 <br />Name of Local Agency Inspector (rf present 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, Haz License Number:481053 <br />Manufacturer Training <br />Manufacturer Component(s) Date <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 state . this document are accurate and in full compliance with legal requirements <br />Technician's Signature: Date: -9-24-14 <br />Received Time Oct.10, 2014 3:57PM No.7310 <br />3. SUMMARY <br />Ur'II♦:J 1 Kr.� u a.. i a <br />Component <br />Pass <br />Not <br />Fail 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 />❑ <br />❑ <br />0 <br />❑ <br />❑ <br />0 <br />0 <br />0 <br />0 <br />❑ <br />0 <br />UDC 3/4 X❑ <br />DSL STP <br />X <br />❑ ❑ <br />0 <br />❑ <br />0 <br />❑ <br />❑ <br />1-2 Secondary <br />X <br />❑ 0 <br />❑ <br />0 <br />0 <br />❑ <br />❑ <br />3-4 Secondary <br />X <br />❑ ❑ <br />❑ <br />0 <br />❑ <br />❑ <br />0 <br />0 <br />❑ ❑ <br />❑ <br />0 <br />❑ <br />0 <br />❑ <br />0 <br />0 ❑ <br />0 <br />❑ <br />0 <br />❑ <br />❑ <br />❑ <br />❑ ❑ <br />❑ <br />❑ <br />0 <br />❑ <br />❑ <br />❑ <br />❑ ❑ <br />D <br />0 <br />❑ <br />D <br />0 <br />0 <br />0 ❑ <br />❑ <br />0 <br />0 <br />D <br />❑ <br />❑ <br />❑ 0 <br />❑ <br />D <br />0 <br />❑ <br />❑ <br />D <br />❑ ❑ <br />❑ <br />0 <br />0 <br />❑ <br />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 state . this document are accurate and in full compliance with legal requirements <br />Technician's Signature: Date: -9-24-14 <br />Received Time Oct.10, 2014 3:57PM No.7310 <br />