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0 <br />0 <br />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 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 />TTAI T <br />1. 1'AlilLll i <br />Facility Name: Estes Express Freight Date of Testing: September 26, 2016 <br />Facility Address: 7611 South Airport Way, Stockton, Ca. 95206 <br />Facility Contact: Jimmy Mozingo I Phone: (209) 982-1841 <br />Date Local Agency Was Notified of Testing: 8/10/2016, by Afford -A -Test <br />Name of Local Agency Inspector (if present during testing): <br />Company Name: R&D Compliance Testing <br />Technician Conducting Test: Benjamin F. Duncan Jr. <br />Credentials: CSLB Licensed Contractor <br />X SWRCB Licensed Tank Tester <br />License Type: Tank Tester <br />License Number: 90-1120/ICC #5246802 -UT <br />Manufacturer <br />Manufacturer Training <br />Component(s) Date Training Expires <br />Caldwell Systems <br />Pi in Sum /UDC July 30, 2017 <br />❑ <br />❑ <br />*X <br />❑ <br />❑ <br />❑ <br />z arrnRa,r s uv nVrrVQrr DRUTT.TC <br />Component <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />Component Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />Annular Tank <br />❑ <br />❑ <br />*X <br />❑ <br />❑ <br />❑ <br />1 ❑ <br />❑ <br />Secondary Pipe <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Piping Sump <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Dispenser Sump <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑❑Id <br />[1 <br />11 <br />11 <br />11[j11❑❑ <br />❑ <br />El❑ <br />EJ <br />El <br />E][IElF]11 <br />ElEl <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 />*See comments page #2. <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: Auc ,7' a.1/re�ua�a���2_ Date: September 26. 2016 <br />