Laserfiche WebLink
`_jtWRCB,January 2002 UCT 2 010 Page of��_ <br /> Secondary Containment TTAW&R M-kromm <br /> This form is intendedfor use by contractors performing periodic testing o/RW1WTgaW4GE&nment 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 ownerloperator for submittal to the local regulatory agency. <br /> I. FACILITY INFORMATION <br /> Facility Name: Rancho San Miguel I Date of Testing: October 20, 2010 <br /> Facility Address: 14vq South Airport Way, Stockton,Ca. 95206 <br /> Facility Contact: Gilbert Silva Phone: (209) 858-0101 <br /> Date Local Agency Was Notified of Testing : 9/8110&10/18/10 by Afford-A-Test <br /> Name of Local Agency Inspector (rfpresent during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: R&D Compliance Testing <br /> Technician Conducting Test: Benjamin F. Duncan Jr. <br /> Credentials: E CSLB Licensed Contractor X SWRCB Licensed Tank Tester <br /> License Type: Tank Tester License Number: 90-1120/ICC 45245802-UT <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Trainin Expires <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Repairs Not Repairs <br /> Component Pass Fail Tested Made Component Pass [ail Tested Made <br /> Annular Tank#1&2 X ❑ p ❑ Fill Riser Sump #2 X ❑ ❑ ❑' <br /> Secondary Pipe #1 X ❑ ❑ ❑ ❑ ❑ Lj <br /> Secondary Pipe 92 X ❑ ❑ ❑ ❑ ❑ r <br /> Secondary Pipe 43 X ❑ ❑ ❑ ❑ ❑ E <br /> Secondary Pipe 94 X ❑ ❑ 0 ❑ ❑ <br /> Secondary Pipe #5 X ❑ ® ❑ ❑ ® ❑ <br /> Piping Sump 41 X ❑ ❑ ❑ ❑ ❑ Li <br /> Piping Sump#2 X ❑ ❑ ❑ [1 ❑ ❑ ❑ <br /> Dispenser Sump #1&2 X ❑ ❑ ❑ ❑ ❑ ❑ <br /> Dispenser Sunup #3&4 X ❑ ❑ ❑ El ❑ ❑ <br /> Dispenser Sump #5&6 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Fill Riser Sump 41 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 1 f'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 stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: Date: 10/20/20 <br /> 1 0 <br /> Page 1 of b <br />