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SWRCB,January 2002 Page of <br /> Secondary Containment Testing Report For ip -Je / -'This form is intended for use by contractors performing periodic testing of UST secondary containment lys em . eV J <br /> appropriate pages of this form to report results for all components tested. The completed form, written test prod� d+�re , and <br /> printouts from tests(ifopplicable),should be provided to the facility owner/operator for submittal to the loci e�tt7atj9j5ncy. <br /> 1. FACILITY INFORMATION <br /> Facility Name: SRH Food&Gas Mart Date of Testing: u <br /> Facility Address: 749 East Charter Way,Stockton,Ca. 95206 <br /> Facility Contact: Johnny I Phone: (209)465-8979 <br /> Date Local Agency Was Notified of Testing: 2/10/2015,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 Tester License Number: 90-1120/ICC#5246802-UT <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> Caldwell Systems Piping Sum s/UDC's July, 2016 <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#1 X ❑ ❑ ❑ Dispenser Sump#7&8 X ❑ ❑ ❑ <br /> Annular Tank#2 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Annular Tank#3 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Secondary Pipe #1 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Secondary Pipe #2 X ❑ ❑ ❑ ❑ ❑ ❑ 1 ❑ <br /> Secondary Pipe #3 X ❑ ❑ ❑ ❑ ❑ ❑ 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 /> Dispenser Sump #5&6 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,thefacts stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: a 1/aszc�z Date: March 18 2015 <br />