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SWRCB,January 2002 Affl&2— <br /> to1, <br /> Secondary Containment Testing Report Form my <br /> This form is intendedfor use by contractors performing periodic testing of UST secondary containment sysbmKI�,.( MENTA! <br /> appropriate pages of this form to report results for all components tested. The completed form, written test procedures, an ....... <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: A G Spanos Jet Center I Date of Testing: February 24,2015 <br /> Facility Address: 4800 South Airport Way,Stockton,Ca.95206 <br /> Facility Contact: Thomas Tilley I Phone: (209)982-1550 <br /> Date Local Agency Was Notified of Testing: 1/14/2015,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 fester License Number: 90-1120/ICC#5246802-UT <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> Caldwell Systems Piping Sum s/Transition Sum s/Return Sums July, 2016 <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Repairs Not Repairs <br /> Component Pass Fail Tested Made Component Pass Fail Tested Made <br /> Annular Tank#1 X ❑ ❑ ❑ Return Piping Sump #2 X ❑ ❑ ❑ <br /> Annular Tank#2 X ❑ ❑ ❑ Transition Piping Sump #1 X ❑ ❑ ❑ <br /> Annular Tank#3 X ❑ ❑ ❑ Transition Piping Sump#2 X ❑ ❑ ❑ <br /> Secondary Pipe#1 X ❑ ❑ ❑ Transition Piping Sump #3 X ❑ ❑ ❑ <br /> Secondary Pipe #2 X- [1 ❑ ❑ El El ❑ LlSecondary Pipe#3 X ❑ ❑ ❑ a[] <br /> Secondary Pipe #4 X ❑ ❑ ❑ <br /> Secondary Pipe#5 X ❑ ❑ ❑ <br /> STP Piping Sump #1 X ❑ ❑ ❑ <br /> STP Piping Sump#2 X ❑ ❑ ❑ <br /> STP Piping Sump#3 X ❑ ❑ ❑ <br /> Return Piping Sump #1 X ❑ ❑ ❑ <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 stated <br /> (iin'this document are accurate and in full compliance with legal requirements <br /> ,t <br /> Technician's Signature: sxln x Date: February 24,2015 <br />