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S WRCB,January 2002 Page_of <br /> Secondary Containment Testing Report Form <br /> This form is intended far use by contractors performing periodic testing of UST secondary containment systems. Use the <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: Plaza Liquors#1 1 Date of Testing: March 22,2012 <br /> Facility Address: 800 South Cherokee Lane,Lodi,Ca.95240 <br /> Facility Contact: Ashok Kumar I Phone: (209)368-0127 <br /> Date Local Agency Was Notified of Testing: 3/7/12 by Afford-A-Test <br /> Name of Local Agency Inspector(ifpresent during testing): <br /> 2. TESTING 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 Type: Tank Tester License Number: 90-1120/1CC#5246802-UT <br /> Manufacturer Training <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 /> Annular Tank#I X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Annular Tank#2&3 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Secondary Pipe #1 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Secondary Pipe#2 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Secondary Pipe #3 X 1 ❑ ❑ ❑ ❑ ❑ ❑ 1 ❑ <br /> Piping Sump#1 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Piping Sump #2 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Piping Sump#3 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Dispenser Sump#1&2 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Dispenser Sump#3&4 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ I ❑ ❑ ❑ ❑ ❑ <br /> ❑ 1 ❑ I ❑ I ❑ ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> Test Fluid Supplied and recovered for reuse by,R&D Compliance Testing. <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,the facts statedgin'thhiiss document are accurate and in full compliance with legal requirements <br /> Technician's Signature: !:: - Date: March 22,2012 <br /> a <br />