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RECEIVED <br /> SEP 2 9 2016 <br /> Secondary Containment Testing Report Form <br /> This form is intended for use by contractors performing periodic testing of UST secondary contaiA HEALTH <br /> appropriate pages of this form to report results for all components tested The completed form, ftren1 e <br /> printouts from tests(ii-applicable), should be provided to the facility owner/operator for submittal to the 1 l a ency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: VANCO TRUCK PLAZA Date of Testing: 8/3/2016 <br /> Facility Address: 1033 W. CHARTER WAY,STOCKTON County SAN JOAQUIN <br /> Facility Contact: I Phone: <br /> Date Local Agency Was Notified of Testing: Thursday,July 28,2016 <br /> Name of Local Agency Inspector(if present during testing): ELAINE <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 Trainine <br /> Manufacturer Component(s) Date Training Ex fres <br /> INCON TS-STS 9/4/2016 <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 ® El ❑ UDC 12-13 SAT MEJ ❑ <br /> 87 VENT SEC ® ❑ UDC 13-14 ❑ <br /> 91 VENT SEC ® ❑ ❑ UDC 14 SAT ❑ ® ❑ El <br /> DSL 1 VENT SEC ® Ll UDC 8-9 SAT ❑ ❑ ❑ <br /> DSL 2 VENT SEC ❑ ❑ UDC 9-10 ❑ <br /> UDC 1-2 ® ❑ ❑ UDC 10 SAT I ❑ L1 I ❑ <br /> UDC 3-4 ® [:] I El I Ll UDC 15-16 ® 1 El ❑ I ❑ <br /> #7 SAT ® ❑ 1 El ❑ LEE10 <br /> UDC 7-8 ® ❑ ❑ ❑ ❑ ❑UDC 5-6 ® ❑ ❑ ❑ ❑UDC11SAT ® ❑ ❑ ❑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 of my knowledge,the facts stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: Date: 8/3/2016 <br /> Secondary Containment Test Results I of 15 <br />