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RECEIVED <br />MAIR 0 6 2014 <br />Secondary Containment Testing Report Form ENVIRONMENTAL <br />This form is intended for use by contractors performing periodic testing of UST secondary containment syste% TU DTPRTMENT <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: Love's Fuel Center (Cover Page I) Date of Testing: 1/14&15, 2014 <br />Facility Address: 1553 Colony Rd., Ripon, Ca. 95366 <br />Facility Contact: Kevin Nickell Phone: (405) 380-5796 <br />Date Local Agency Was Notified of Testing: 12/16/13, by Afford -A -Test <br />Name of Local Agency Inspector (f present during testing): <br />L. I L,51 11NU 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 Tvpe: Tank Tester License Number: 90-1120ACC #5246802 -UT <br />Manufacturer Training <br />Manufacturer Component(s) Date Training Expires <br />3. SUMMARY OF TEST RESULTS <br />Component <br />p <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />Component <br />Not Repairs <br />Pass Fail Tested Made <br />Annular Tank #1 <br />X <br />❑ <br />❑ <br />❑ <br />Secondary Pipe #9 <br />❑ ❑ X ❑ <br />Annular Tank #2 <br />X <br />❑ <br />❑ <br />❑ <br />Piping Sump #1 <br />X ❑ ❑ ❑ <br />Annular Tank #3 <br />X <br />❑ <br />❑ <br />❑ <br />Piping Sump #2 <br />X ❑ ❑ ❑ <br />Annular Tank #4&5 <br />X <br />❑ <br />❑ <br />❑ <br />Piping Sump #3 <br />X ❑ ❑ ❑ <br />Secondary Pipe #1 <br />X <br />❑ <br />❑ <br />❑ <br />Piping Sump #4 <br />X ❑ ❑ ❑ <br />Secondary Pipe #2 <br />X <br />❑ <br />❑ <br />❑ <br />Piping Sump #5 <br />X ❑ ❑ ❑ <br />Secondary Pipe #3 <br />X <br />❑ <br />❑ <br />❑ <br />Piping Sump #6 <br />X ❑ ❑ ❑ <br />Secondary Pipe #4 <br />X <br />❑ <br />❑ <br />❑ <br />Piping Sump #7 <br />X ❑ ❑ ❑ <br />Secondary Pipe #5 <br />X <br />❑ <br />❑ <br />❑ <br />Piping Sump #8 <br />X ❑ ❑ ❑ <br />Secondary Pipe #6 <br />X <br />❑ <br />❑ <br />❑ <br />Piping Sump #9 <br />X ❑ ❑ ❑ <br />Secondary Pipe #7 <br />X <br />❑ <br />❑ <br />❑ <br />Piping Sump #10 <br />X ❑ ❑ ❑ <br />Secondary Pipe #8 <br />X <br />❑ <br />I ❑ <br />❑ <br />Dispenser Sump #1 &2 <br />X Fi I ❑ I ❑ <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 />See comments pages 6 & 12 of this Report for components not tested. <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: —zw-f,-W ra �ureoart Date: January 14&15, 2014 <br />