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SWRCB,January 2002 Page_of <br /> Secondary Containment Testing Report Form <br /> This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the <br /> appropriate pages of thisform 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 /> Facility Name: GEMCO Date of Testing: 5/27/2015 <br /> Facility Address: 1022 FRONTAGE ROAD <br /> Facility Contact: JOHAL Phone: (209)456-7474 <br /> Date Local Agency Was Notified of Testing: 5/19/2015 <br /> Name of Local Agency Inspector(fpresent during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: KAISER COMMERCIAL PETROLEUM <br /> Technician Conducting Test: GREG KAISER <br /> Credentials: ®CSLB Licensed Contractor 0 SWRCB Licensed Tank Tester <br /> License Type: A License Number. 859535 <br /> Manufacturer Tminine <br /> Manutac[urer <br /> Component(s) Date Training Expires <br /> CALDWELL LEVEL CHANGE INDICATOR 1/7/2018 <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> REG STP SUMP ® 0 0 0 UDC IOB& 11B ® 0 0 <br /> PREM STP SUMP ® 0 0 0 UDC 11A& 12A ® 0 0 0 <br /> EAST DISEL PIPING SUMP ® 0 0 ® UDC 13A&14A ® 0 0 0 <br /> WEST DIESEL PIPING SUMP ® 0 0 0 SECONDARY PIPE STPI ® 0 0 0 <br /> UST ANNULAR ® 0 0 0 SECONDARY PIPE STP2 ® 0 0 0 <br /> UDC 3&4 ® 0 0 0 EAST TRANSITION SUMP 0 0 0 0 <br /> UDC 1&2 ® 0 0 0 SECONDARY PIPE ® 0 0 0 <br /> UDC 5A&6A ® 0 0 0 WEST TRANSITION SUMP 0 0 0 0 <br /> UDC 611&7B ® 0 0 0 SECONDARY PIPE ® 0 0 0 <br /> UDC 7A&8A ® 0 0 0 REG FILL SUMP ® 0 0 0 <br /> UDC 8B&9B ® 0 0 0 PREMIUM FILL SUMP ® 0 0 0 <br /> UDC 9A&10A I ® 1 0 1 0 1 0 <br /> If hydrostatic testiq,g was performed,describe what was done with the water after completion o <br /> Test fluid supplied and recovered for reuse by Kaiser Commercial Petroleum. <br /> MAR 06 2017 <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTIN(ghW#JQ~TAL HEALTH <br /> To the best of my knowledge,thefac d this document are accurate and In full compliance wit��ils <br /> Technician's Signature: Date: 5/27/2015 <br />