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1 03/13/2012 15:24 0000000 0t`t`�t`t`�EEt`@�@�@� PAGE 02/06 <br /> Secondary Containment Testing Report Form <br /> Fur Use by Unidocs Member Agencies or where approved by your Local Jurisdiction <br /> Authority Cited. Heath and Safety Code§25293: Tide 23 CCR§2637(a)(4) <br /> This form, or the standard form develped by the State Water Resources Control Board (SWRCB), must be used <br /> by contractors performing periodic testing of underground storage tank (UST) secondary containment systems <br /> in Unidocs member agency jurisdictions. The completed form, written test procedures,data collection logs, and <br /> printouts from test equipment (if applicable), must be provided to the facility owner/operator for submittal to <br /> the local regulatory agency within 30 days of the test date. <br /> SWRCB requires that the entire volume of each sump and undcr-dispenser containment(UDC) system be tested <br /> if the sump/UDC is not equipped with a continuous monitoring system that shuts down the pump when a leak is <br /> detecetd or the leak detection sensor fails or is disconnected. rs=5wRC6 Local Guidon=Una w-1601 <br /> Systems where leak detection equipment continuously monitors both primary and secondary containment (e.g. <br /> systems that are hydrostatically monitored or under constant vacuum) are exempt from periodic testing <br /> rcquirements. 123 CCR§2637(9)(6)) <br /> In the case of pressure/vacuum testing, gay loss in pressure/vacuum daring the course of the test shall be <br /> considered a failed test,regardless of the manufacturer's criteria for declaring a passed test. 123 CCR§2637(x)(2)] <br /> A. Facility Information <br /> Facility Name: Vallg Pacific Petroleum Services Date of resting: Janua 11 2012 <br /> Site Address: 3550 S.Highway 99,Stockton,CA <br /> Facility Contact: Mike Eliason Phone: 8o0-266-3782 <br /> Date Local Agency was Notified of Testing: 1-3.12 <br /> Name of Local Agency Inspector(ifpreseni during testing): <br /> B. Testing Contractor Information <br /> Company Name: Kern County Construction,Inc. <br /> Credentials: ®CSLA-Licensed Contractor; ❑SWRCB-Licensed Tank Tester <br /> License Type: ®A; ❑C-10; ❑C-34;❑C-36;❑C-61 (D40) License Number: 481053 <br /> Name of Technician Conducting Tests: Josh Simmons <br /> Training by Equipment Manufacturer <br /> Manufacturer Component(s) Date Training Expires <br /> Incon TS-STS 12-2-12 <br /> C. Certification by Technician Responsible for Conducting Testing <br /> To the best of my knowledge, the facts stated in this document are accurate and in full compliance with <br /> legal requirements. <br /> Technician's Signature:_. Date: t l_l Z <br /> UN-054-1/5 w .unidoeton; 0226/02 <br />