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"RECEIVED <br /> Secondary Containment Testing Report Form SEP 2 9 2016 <br /> This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the <br /> appropriate pages of this form to report results for all components tested The completed form, written��tes__tPPr���o��c�eed��u��rreTess,�,��an�,d��p� <br /> printouts from tests(if applicable), should be provided to the facility owner/operator for submitti hiloOdN WDID age A4-T H <br /> 4. FACILITY INFORMATION DEPARTMENT <br /> Facility Name: VANCO TRUCK PLAZA Date of Testing: 8/3/2016 <br /> Facility Address: 1033 W. CHARTER WAY County SAN JOAQUIN <br /> Facility Contact: TERRY Phone: <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(if present during testing): <br /> 5. 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 9/1/2016 <br /> 6. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> OCT. 100 STP ® ❑ OCT. 100 FILL ❑ <br /> 87 STP ® ❑ 87 FILL ❑ ❑ <br /> 91 STP ® ❑ ❑ 91 FILL ❑ ❑ <br /> DSL 1 STP ® ❑ ❑ ❑ DSL 1 FILL ® ❑ ❑ ❑ <br /> DSL 2 STP ❑ ❑ DSL 2 FILL ❑ ❑ <br /> OCT. 100 SEC PROD FEED] <br /> TRANS/FILTER SUMP ❑ ❑ <br /> 87 SEC PROD ❑ TRANS/FILTER SEC IT <br /> 91 SEC PROD OCT. 100 ANNULAR ❑ ❑DSL 1 SEC PROD LD <br /> ANNULAR ❑ ❑DSL 2 SEC PROD ❑ ANNULAR ® ❑ ❑ ❑DSL SYPHON SEC ❑ L 1 ANNULAR ® ❑ ❑ ❑L2ANNULAR ❑ ❑ <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 2 of 15 <br />