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09110/2015 11: 56 5308248776 LCPJES PAGE 06/12 SWRCfl,January 2002 -up Ab IV E U Secondary Containment Testing Report Form SEP 10 2010 This form is intended for use by contractors performingperiodic testing of UST secondary containment systems. Use the appropriate pages of this farm to report results for all components tested. The completed form, written test p"N" n�IVB ENTAL printouts from tests(if applicable),should be provided to the facility ownerloperator for submittal to the 100a1 r,490k"a'SM0PT+Ar:k17 1. FACILITY INFORMATION Facility Name: Love's Fuel Center Date of Testing: August 26,2015 Facility Address: 1553 Colony Rd,Ripon,Ca.95366 Facility Contact Jessie Diaz Phone: (405)687-1060 Date Local Agency Was Notified of Testing: 8/14/2015,by Afford-A-Test Name of Local..Agency Inspector(if present during te.eting): 2. TESTING CONTRACTOR INFORMATION Company Name: R&D Co fiance Testing Technician Umductitig Test: Benjamin:F'.Duncan Jr. Credentials: ❑CSLB Licensed Contractor X SR'RCB Licensed Wank Teeter License Type. Tank Tester License Number;90-1120/ICC*5246802-UT Manufacturer Trainhna Manufacturer Co onen s) Date Training Expires Caldwell$ turns LTDC fuly,2017 3. SUNEY AR'Y'OF TEST RESULTS Component Pass Rall Not Repairs No Component pass FaU t Repairs Tested Made Tested I Made Dispenser Sump#17&18 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑� ❑ Ll ❑ ❑ 11 El L ❑ ❑ ❑ 1 ❑ ❑ If hydrostatic testing was performed,describe what was done with the water after completion of tests: Test fluid supplied and recovered for reuse by,lz&D Compliance Testing. CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING To the best of my knowledge,the faces stated in this document are accurate and in full compllame%*h legal requirements Technician's Signature: a Ery Zg Date: August 26,2015