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SWRCB,January 2002 Page of <br /> Secondary Containment Testing Report Form <br /> This form is intendedfor use by contractors performing periodic testing of UST secondary containment systems. Use the <br /> appropriate pages oj'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 Date of Testing: 1/17&18, 201 1 <br /> Facility Address: 1553 Colony Rd., Ripon,Ca. 95366 <br /> Facility Contact: Kevin Nickell Phone: (405)380-5796 <br /> pDate Local Agency Was Notified of Testing: I 1/16/10 by Afford-A-Test <br /> Name of Local Agency Inspector (fpresent during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: R&D Compliance Testing <br /> Technician Conducting Test: Benjamin F.Duncan Jr. <br /> Credentials: D CSLB Licensed Contractor X SWRCB Licensed Tank Tester <br /> License Type: Tank Tester License Number:90-1120/1CC#5246802-UT <br /> Manufacturer Training I� <br /> Manufacturer Component(s) Date Training Expires <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> Dispenser Sump #3&4 X I] ❑ ❑ Dispenser Sump #23s&24m X ❑ (: <br /> _Dispenser Sump #5&6 X 1j ❑ ❑ Dispenser Sump #24s&25m X ❑ C.:I <br /> Dispenser Sump#7&8 X ❑ ❑ ❑ Dispenser Sump #25s&26m X ❑ ❑ <br /> Dispenser Sump #9&10 X ❑ ❑ ❑ Dispenser Sump #26s&27m X ❑ ❑ <br /> !r- <br /> Dispenser Sump#11&12 X ❑ ❑ ❑ Dispenser Sump#27s X ❑ U <br /> Dispenser Sump #13&14 X I ❑ ❑ ❑ Fill Riser Sump #1 X ❑ ❑ i.. <br /> Dispenser Sump#15&16 X 1..1 ❑ ❑ Fill Riser Sump #2 X U ❑ 7 <br /> Dispenser Sump#17&18 X ❑ ❑ rl Fill Riser Sump #3 X L ❑ <br /> Dispenser Sump#1.9&20 X -7 ❑ LiFill Riser Sump #4 X � <br /> Dispenser Sump#21 m X ❑ ❑ ❑ Fill Riser Sump #5 X r ❑ ' <br /> Dispenser Sump# 21 s&2'2m X G ❑ ❑ ❑ ❑ ❑ <br /> Dispenser Sump# 22s&2am X ❑ ❑ ❑ ❑ 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 /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,lh:e facts stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: �fa'�s�taz �� D Date: January 1&18, 2011 <br />