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SWRCB, January 2002 Secondary Containment Testing Report Form APR 0 9 2015 This form is intended for use by contractors performing periodic testing of UST secondary containtfiWi e a the appropriate pages of this form to report results for all components tested The completed form, writtenR �SA11j H printouts from tests (f applicable), should be provided to the facility owner/operator for submittal to the local re riigency. 1. FACILITY INFORMATION Facility Name: VILLAGE WEST MARINA Date of Testing: 03-19-2015 Facility Address: 6649 EMBARCADERO DRIVE, STOCKTON, CA 95217 Facility Contact: TIM FONTAINE I Phone: (209) 951-1551 Date Local Agency Was Notified of Testing: 03-17-2015 Name of Local Agency Inspector (f present during testing): 11 -rvcmnv1-- rnNTP A T(YP 1 V011MATION Company Name: KAISER COMMERCIAL PETROLEUM Technician Conducting Test: GREG KAISER Credentials: ® CSLB Licensed Contractor 0 SWRCB Licensed Tank Tester License Type: A License Number: 859535 Manufacturer Training Manufacturer Component(s) Date Trainin ;Ex ires CALDWELL SUMP TESTER 01-07-2016 I c1TX4V[ARv nF TEST RF,SULTS ent Pass Fail Not Tested Repairs Made Component Pass Fail Not Tested Repairs Made MP VDEESEL ® ❑ ❑ ROM ON SUMP TO 2 ® ❑ ❑ ❑ MP ® ❑ ❑ ❑ ❑ ❑ MP 1 ® ❑ ❑EL LINE FROM SUMP TO h ❑ ❑❑ON TRANSITION SUMP 2 ❑ ❑ ❑ ❑ ❑ ❑ 91 ANNULAR ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ RED DUEL ANNULAR ® ❑ ❑ 1 ❑ ❑ ❑ ❑ ❑ 91 LINE TO TRANSITION ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ RED DIESEL LINE TO TRANSITION SUMP ® ❑ ❑ ❑ ❑ ❑ ❑ 11 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑❑ ❑ ❑ ❑ [1❑ ❑ If hydrostatic testing was performed, describe what was done with the water after completion of tests: WATER WAS FILTERED AND RETURNED TO KCP's HOLDING TANK. CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING To the best of my knowledge, the facts Mated In this document are accurate and in full compliance with legal requirements Technician's Signature: ,fti L� Date: 03-19-2015