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- - C <br /> SEP 2 S 2016 <br /> Secondary Containment Testing Report Form <br /> This form is intended for use by contractors performing periodic testing of UST secondary containment syFt�NV I RQNM ENTAL HEALTH <br /> appropriate pages ofthis form to report results for all components tested. The completedform, written test procedtj!y-EPAPTM ENT <br /> printouts from tests('(applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: VANCO TRUCK PLAZA Daze of Testing: 8/3/2016 <br /> Facility Address: 1033 W.CHARTER WAY,STOCKTON County SAN JOAQUIN <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing <br /> Name of Local Agency Inspector(ifpresent during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: B.Z.Service Station Maintenance <br /> Technician Conducting Test: DAVID ROUSE <br /> Credentials: ®CSLB Licensed Contractor ❑ SWRCB Licensed Tank Tester <br /> License Type: ICC License Number:433159 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> INCON TS-STS <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> OCT. 100 = 0 1 UDC 12-13 SAT Ej <br /> 87 VENT SEC [0111 10 UDC 13-14 ® ❑ <br /> 91 VENT SEC UDC 14 SAT <br /> DSL 1 VENT SECUDC 8-9 SAT <br /> DSL 2 VENT SEC UDC 9-10 <br /> UDC 1-2 RF- UDC 10 SAT <br /> UDC 34 UDC 15-16 <br /> #7 SAT <br /> UDC 7-8 ® ❑ <br /> UDC 5-6 ❑ <br /> UDC 11 SAT RE 0 <br /> UDC 11-12 <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> TOOK AS TEST WATER <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best ofmy knowledge,thee fJacc^ts/stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: '�!//�/TDate:8/3/2016 <br /> v <br /> Secondary Containment Test Results I of 15 <br />