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;�j RECEIVED <br /> S W RCB,January 2002 Page _ _of <br /> Secondary Containment Testing Report Form <br /> FEB 01 2011 <br /> This form is intended for use by contractors performing periodic testing of UST secondary containmenlOWN 10814*L HEALTH <br /> appropriate pages of'this form to report results for all components tested. The completed form, written test W&9MW8aPNWE8 <br /> printouts from tests (f 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 Date of Testing: 1/17&18,201 1 <br /> _.. _— -- —._......... <br /> . <br /> Facility Address: 1553 Colony Rd., Ripon,Ca. 95366 <br /> I Facility Contact: Kevin Nickell Phone: (405)380-5796 <br /> Date Local Agency Was Notified of Testing: ---1.1/16/10 by Afford-A-Test <br /> Name of Local Agency Inspector.(fpresent during testing): <br /> i <br /> —.. <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name,_R&D Compliance Testing <br /> Technician Conducting Test: Benjamin F. Duncan Jr. <br /> is Credentials: D CSLB Licensed Contractor X SWRCB Licensed Tank Tester <br /> License Type: Tank Tester License Number:90-1120ACC#5246802-tJT <br /> Manufacturer Trainine <br /> Manufacturer Component(s) Date Training Expires <br /> 3. SUMMARY OF TEST RESULTS— <br /> Not Repairs <br /> Component Pass Fail Not Repairs Component Pass Fail . <br /> Tested Made i tested Made <br /> Annular 1'an.k#1 X J ❑ ❑ Secondary Pipe#9 X ❑ ❑ <br /> Annular Tank#2 X (fit ❑ ❑ Piping Sump#1 X ❑ ❑ I <br /> [1 Piping Sump#2 X L,! LI <br /> Annular Tank#3 X J�_� _ <br /> j Annular Tank #4&5 X ❑ fi ❑ Piping Sump#3 X ❑ ❑ <br /> Secondary Pipe#1 X t-1 l❑ ❑ Piping Sump#4 X ❑ ❑ 1 i h <br /> Secondary Pipe#2 X ❑ ❑ (� Piping Sump#5 X L ❑ <br /> Secondary Pipe#3 X ❑ J ❑ ! Piping Sump#6 X Ll ❑ I.. I <br /> Secondary Pipe#4 X ❑ Li ii Piping Sump #7 X ❑ ❑ r. <br /> Secondary Pipe#51 X v 0 [1Piping Sump#8 X ❑ <br /> Secondary Pipe#6 _ X (.-.7 (:::+ U Piping Sump #9 X ❑ ❑ i-! 'i <br /> Secondary Pipe#7 X 11 (-j L) Piping Sump#10 X 1-1 ❑ :;! <br /> Secondary Pipe#8 X (. ❑ Dispenser Sump #1&2--tX <br /> if hydrostatic testing was performed, describe what was done with the water after completion of tests: <br /> Test Flttid 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: �� �� 2 Date: January, 17&18,2011 <br /> Si c, „�:, <br />