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GEI VEV <br /> SWRCB,January 2002e of <br /> Jxff��0i5 <br /> Secondary Containment Testing Report Form <br /> �NVI <br /> This form is intendedfor use by contractors performing periodic testing of UST secondary containment systt�ts. Q- ,N-M.-'EN7AL. <br /> appropriate pages of this form to report results for all components tested. The completed form, written test procedurerP fc,�,— <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 I Date of Testing: December 29, 2014 <br /> Facility Address: 1553 Colony Rd.,Ripon,Ca.95366 <br /> Facility Contact: Jesse Diaz Phone: (405)687-1060 <br /> Date Local Agency Was Notified of Testing: 11/13/14,by Afford-A-Test <br /> Name of Local Agency Inspector(if present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: R&D Compliance Testing <br /> Technician Conducting Test: Benjamin F.Duncan Jr. <br /> Credentials: 0 CSLB Licensed Contractor X SWRCB Licensed Tank Tester <br /> License Type: Tank Tester License Number:90-1120/ICC#5246802-UT <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> Caldwell Systems Level Chane Indicator July, 2016 <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Repairs Not Repairs <br /> Component Pass fail Tested Made Component Pass Fail Tested Made <br /> Secondary Pipe#1-Main X ❑ ❑ ❑ Dispenser Sump#24-S&24-M X ❑ ❑ iJ <br /> Secondary Pipe#21-S X ❑ ❑ ❑ Dispenser Sump#25-S&26-M X ❑ ❑ ❑ <br /> Secondary Pipe#22-S X ❑ ❑ ❑ Dispenser Sump#26-S&27-M X ❑ ❑ ❑ <br /> Secondary Pipe#23-S X ❑ ❑ ❑ Dispenser Sump#27-S X ❑ ❑ ❑ <br /> Secondary Pipe#24-S X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Secondary Pipe#25-S X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Secondary Pipe#26-S X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Secondary Pipe#27-S X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Dispenser Sump#21-M X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Dispenser Sump#21-S&22-M X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Dispenser Sump#22-S&23-M X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Dispenser Sump#23-S&24-M X ❑ n ❑ ❑ ❑ ❑ ❑ <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: f WWMjW Date: December 29,2014 <br />