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kECEIVED <br />SWRCB, January 2002 Page of <br />DEC 2 9 2016 <br />Secondary Containment Testing Report Form <br />This form is intended for use by contractors performing periodic testing of UST secondarPtV)i QW9WA LsHEA LT H <br />appropriate pages of this form to report results for all components tested. The completed form, wtD@RTs, and <br />printouts from tests (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />4. FACILITY INFORMATION <br />Facility Name: Love's Fuel Center (Cover Page ll) Date of Testing: 12/12& 13, 2016 <br />Facility Address: 1553 Colony Rd., Ripon, Ca. 95366 <br />Facility Contact: Jessie Diaz Phone: (405) 687-1060 <br />Date Local Agency Was Notified of Testing: 11/23/2016, by Afford -A -Test <br />Name of Local Agency Inspector (if present during testing): <br />5. TESTING CONTRACTOR INFORMATION <br />Company Name: R&D Compliance Testing <br />Technician Conducting Test: Benjamin F. Duncan Jr. <br />Credentials: ❑ CSLB Licensed Contractor X SWRCB Licensed Tank Tester <br />License Type: Tank Tester <br />License Number: 90-1120/ICC 45246802 -UT <br />Manufacturer Trainine <br />Manufacturer Component(s) Date Training Expires <br />Caldwell Systems Piping Sum s/UDC's/Fill Riser Sums July 30, 2017 <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />6. SUMMARY OF TEST RESULTS <br />Component <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />Component <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />Piping Sump #6 <br />X <br />❑ <br />❑ <br />❑ <br />Dispenser Sump #15&16 <br />X <br />❑ <br />❑ <br />❑ <br />Piping Sump #7 <br />X <br />❑ <br />❑ <br />❑ <br />Dispenser Sump #17&18 <br />X <br />❑ <br />❑ <br />❑ <br />Piping Sump #8 <br />X <br />❑ <br />❑ <br />❑ <br />Dispenser Sump #19&20 <br />X 1 <br />❑ <br />❑ <br />❑ <br />Piping Sump #9 <br />X <br />❑ <br />❑ <br />❑ <br />Dispenser Sump #21m <br />X <br />❑ <br />❑ <br />❑ <br />Piping Sump #10 <br />X <br />❑ <br />❑ <br />❑ <br />Dispenser Sump #21s&22m <br />X <br />❑ <br />❑ <br />❑ <br />Dispenser Sump #1&2 <br />X <br />❑ <br />❑ <br />❑ <br />Dispenser Sump #22s&23m <br />X <br />❑ <br />❑ <br />❑ <br />Dispenser Sump #3&4 <br />X <br />❑ <br />❑ <br />❑ <br />Dispenser Sump #23s&24m <br />X <br />❑ <br />❑ <br />❑ <br />Dispenser Sump #5&6 <br />X <br />❑ <br />❑ <br />❑ <br />Dispenser Sump #24s&25m <br />X <br />❑ <br />❑ <br />❑ <br />Dispenser Sump #7&8 <br />X <br />❑ <br />❑ <br />❑ <br />Dispenser Sump #25s&26m <br />X <br />❑ <br />❑ <br />❑ <br />Dispenser Sump #9&10 <br />X <br />❑ <br />❑ <br />❑ <br />Dispenser Sump #26s&27m <br />X <br />❑ <br />❑ <br />❑ <br />Dispenser Sump #11&12 <br />X <br />❑ <br />❑ <br />❑ <br />Dispenser Sump #27s <br />X <br />❑ <br />❑ <br />❑ <br />Dispenser Sump #13&14 <br />X <br />❑ <br />I ❑ <br />I ❑ <br />Fill Riser Sump #1 <br />X 1 <br />❑ <br />❑ <br />❑ <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />Test Fluid Supplied by Site and Disposed of in On Site Separator Tank. <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: rntn �` �� Date: December 12&13, 2016 <br />