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Mar 08 16011JP Petroleum Service Q163724873 p. <br /> APR 06 21016 <br /> SWRCB,January 2002 page of <br /> Secondary Containment Vesting 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 this form to report results for all components tested The completed form, written test procedures. and <br /> printouts from tests(if applicable), should he provided to the facility owner/operator for submittal to the local regularory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Country Market Place hate of Testing: 7/14/15 <br /> Facility Address: 1789 W.Chaner Way,Stockton Ca <br /> Facility Contact: TI Phone: 209-535-1096 <br /> Date Local Agency Was Notified of Testing : <br /> Name of local Agency Inspector(tf present during testing}_ <br /> 11 <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: IP Petroleum Service <br /> Technician Conducting Test: Gabe Garcia <br /> Credentials: x CSLB Licensed Contractor 0 SWRCB Licensed Tank Tester <br /> License Type: A License Number: 811471 ICC#5281582 <br /> Manufacturer TraininP <br /> Manufacturer Component{s} Date Training Expires <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Repairs <br /> Tested Made Component Pass Fail �Teqsted Made <br /> Annular 1 ❑ x ❑ ❑ UDC 1-2 x ❑ C <br /> Annular 2 x © ❑ ❑ UDC 3-4 x ❑ ❑ G <br /> Sump 1 x ❑ ❑ ❑ UDC 5-6 ❑ x ❑ ❑ <br /> Sump 2 x ❑ ❑ ❑ UDC 7-8 x ❑ ❑ Cl <br /> Line 1 ❑ ❑ x ❑ UDC 9-10 ❑ x ❑ ❑ <br /> Line 2 x ❑ ❑ ❑ UDC 11-12 ❑ -jx ❑ <br /> Line 3 x ❑ ❑ ❑ ❑ ❑ J ❑ <br /> Line 4 x ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ C ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ I ❑ ❑ ❑ i ❑ ❑ <br /> If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br /> Water was filtered and returned to holding tank. <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To Abe best of my knawledrge,the facts slated in this document are accurate and to full compliance with legal requirements <br /> Technician's Sianature._0t4w Date:-7/14i15---- <br />