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{ <br /> RECEIVED <br /> AUG 16 2018 <br /> Secondary Containment Testing Report Fri ' RONhIENTAL HEALTH <br /> 1)[-.PAR'rN1ENT <br /> This form is intendedfor use by contractors performingperiodic 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#3641 Date of Testing:07/25/18 <br /> Facility Address: 1210 E.Hammer Ln., Stockton CA 95210 <br /> Facility Contact: Phone (209)477-3111 ❑Initial ®Repair Test <br /> Date Local Agency Was Notified of Testing: 07/20/18 ❑6 Month []Other <br /> Name of Local Agency Inspector(i(present during testing): Elena Manzo ❑Triennial <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: ABLE Maintenance,Inc. <br /> Technician Conducting Test: Jeff Carmo/I.C.C.#8855714 <br /> Credentials: ❑p CSL13 Licensed Contractor ❑SWRCB Licensed Tank Tester ®ICC UST Service Technician <br /> License Type: A.B,HAz.,CIO License Number:312844 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> Available upon request <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> 91 Primary Product © ❑ <br /> 91 Secondary Product <br /> ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ 13 <br /> ❑ ❑ ❑ ElE3 ❑ ❑ ❑ <br /> ❑ ❑ 0 ❑ <br /> ❑ ❑ ❑ <br /> ❑ ❑ ❑ <br /> ❑ 11 ❑ ❑ ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> For any equipment capable of generating a print out of test results,you must attach a copy <br /> of the test report to this certification ❑ System printout attached. <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,the facts stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: _._ —_. Date: 07/25/18 <br />