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SWRCB, January 2002 <br />I lot] *91 a .0 "41-:11 <br />D E C NKU of <br />Secondary Containment Testing Report Form <br />This form is intended for use by contractors performing periodic testing of UST secondary containment i N �T�� �l���� <br />appropriate pages of this form to report results for all components tested. The completed form, written t r r��lllrl <br />printouts from tests (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />7. FACILITY INFORMATION <br />Facility Name: Love's Fuel Center (Cover Page I11) Date of Testing: 12/12&13, 2016 <br />Facility Address: 1553 Colony Rd., Ripon, Ca. 95366 <br />Facility Contact: Jessie Diaz I 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 (f present during testing): <br />8. 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 License Number: 90-1120/1CC #5246802 -UT <br />Manufacturer Training <br />Manufacturer Component(s) Date Training Expires <br />Caldwell Systems Piping Sum s/UDC's/Fill Riser Sums July 30, 2017 <br />9. SUMMARY OF TEST RESULTS <br />Component <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />Component Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />Fill Riser Sump #2 <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Fill Riser Sump #3 <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Fill Riser Sump #4 <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Fill Riser Sump #5 <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />El <br />El <br />El <br />❑ <br />11 <br />11❑ <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: �ej e� � Date: December 12&13, 2016 <br />