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03/18/2015 02:13PM 6616349233 KERN CONSTRUCTION PAGE 08/27 <br /> SWRCB,January 2002 • • <br /> Page I 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 this form 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: Valley Pacific Petroleum(Shane and Dave's) Date of Testing: 3-16-15 <br /> Facility Address: 3550 S.Highway 99, Stockton,CA <br /> Facility Contact: Mike Eliason Phone: <br /> Date Local Agency Was Notified of Testing: 3-12-15 <br /> Name of Local Agency Inspector(fpresent during testing): <br /> 2. TESTING CONTRACTOR INFORMATION MAR 18 2015 <br /> Company Name: Kern County Construction,Inc. <br /> Technician Conducting Test: Josh Simmons MUMMA <br /> Credentials: x CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester <br /> License Type: A,B,Hat License Number:481053 <br /> Manufacturer Training <br /> Manufacturer component(s)) Date Training Expires <br /> INCON TS-STS 10-11-15 <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Not Repairs <br /> p Tested Made Component Pass Fail Tested Made <br /> UDC 1/2 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 87/Red DSL Annular X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 87 Secondary X p ❑ ❑ ❑ ❑ ❑ ❑ <br /> Red DSL Secondary X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 87S X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Red DSL STP X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ 1 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ I EFT ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> Water returned to test tank for re-use. <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,the facts sta in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: Date: 3-16-15 <br /> Received Time Mar. 18. 2015 3: 16PM No. 8366 <br />