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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 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: VALERO I Date of Testing: 1-20-10 <br /> Facility Address: 1001 E.YOSEMITE,MANTECA,CA 95336 <br /> Facility Contact: BILLA I Phone: 209-825-4569 <br /> Date Local Agency Was Notified of Testing: 12-31-09 <br /> Name of Local Agency Inspector(if present during testing): MUNI <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: SST-Service Station Testing <br /> Technician Conducting Test: Heath A.McEver <br /> Credentials: 0 CSLB Licensed Contractor X SWRCB Licensed Tank Tester <br /> License Type: Service Technician License Number: 04-1677 <br /> Manufacturer Training <br /> Manufacturer Com nent(s) Date Training Expires <br /> OPW SPILL BUCKETS 2-13-10 <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> 87 FILL BUCKET X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 91 FILL BUCKET X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> DSL FILL BUCKET X ❑ ❑ ❑ ❑ ❑ D ❑ <br /> D ❑ ❑ D ❑ I D ❑ D <br /> D D D ❑ D ❑ ❑ ❑ <br /> D D D Cl ❑ ❑ D D <br /> ❑ D ❑ ❑ ❑ D D ❑ <br /> ❑ D D D ❑ 1 D D D <br /> ❑ ❑ ❑ D ❑ D D D <br /> D ❑ ❑ D ❑ D ❑ ❑ <br /> ❑ 1 ❑ 1 ❑ 1 D ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> Left on site <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,the facts stat this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: Date: <br />