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08/14/2012 20:38 (209)465-4988 MaryAnn Henderson Page 12/19 <br /> 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(f applicable),should be provided to the facility ownerloperator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: QUICK SHOP VALERO I Date of Testing: 01/24/2012 <br /> Facility Address: 1001 E YOSEMITE.MANTECA,CA 95336 <br /> Facility Contact: MGR I Phone: 209-825-4569 <br /> Date Local Agency Was Notified of Testing: 01/11/2012 <br /> Name of Local Agency Inspector(if present during testing): MICHELLE HENRY <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: SERVICE STATION TESTING,SST,INC. <br /> Technician Conducting Test: CHARLES FERRUCCI <br /> Credentials: X CSLB Licensed Contractor 0 SWRCB Licensed Tank Tester <br /> License Type: A,B,C10,C20,C36 License Number:962520 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Ex ires <br /> INCON TS. STS 12-29-2013 <br /> i <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> REGULAR ANNULAR X ❑ ❑ ❑ ❑ ❑ ❑ 0 <br /> PREM-DIESEL ANNULAR X 0 0 0 0 0 0 ❑ <br /> DISP 1/2 X 0 ❑ p 1 ❑ 0 ❑ ❑ <br /> DISP 3/4 X 0 ❑ ❑ ❑ ❑ ❑ ❑ <br /> DISP 5/6 X ❑ ❑ ❑ 0 ❑ 0 ❑ <br /> DISP 7/8 X ❑ 0 ❑ 0 0 0 0 <br /> REGULAR SEC LINE 0 ❑ X 0 ❑ 0 ❑ ❑ <br /> PREMIUM SEC LINE X ❑ ❑ 0 ❑ 0 ❑ 0 <br /> DIESEL PROD LINE X ❑ ❑ 0 ❑ ❑ ❑ ❑ <br /> REGULAR STP ❑ 0 X ❑ 0 ❑ ❑ 0 <br /> PREMIUM STP X 0 0 0 0 ❑ ❑ ❑ <br /> DIESEL STP ❑ 0 0 0 0 0 ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> Taken off site as test water. <br /> CERTIFICATION OF TEC AN RE�NSIB E FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,the cts a this doccurate and in full compliance with legal requirements <br /> Technician's Signature: l ��;. Date: 01/24/2012 <br />