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S W RC ORECEIVW_B,January 2002 of <br /> Secondary Containment Testing Report FMint 8 2011 <br /> This form is intended for use by contractors performing periodic testing of UST secondaryi ment s stems. Use the <br /> appropriate pages of this form to report results for all components tested. The completed a ry KSWd Ads, and <br /> printouts from tests(f applicable), should be provided to the facility owner/operatorfor submit a ' '( %ulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: SRH Food&Gas Date of Testing: March 17,2011 <br /> Facility Address: 749 East Charter Way, Stockton,Ca. 95206 _ <br /> Facility Contact: Muhammad Rizwan I Phone: (209)465-8979 <br /> Date Local Agency Was Notified of Testing : 3/16/11 Ok Per Local CUPA <br /> Name of Local Agency Inspector(ifpresent during testing): Stacy Rivera, REHS <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 45246802-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 #2 Reg. 87 X ❑ ❑ ❑ ❑ ❑ ❑ <br /> Annular Tank #3 Super 91 X ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ -- <br /> ❑ ❑ ❑ ❑ ❑ ❑ - <br /> ❑ ❑ ❑ _ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ - <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br /> Annular Test after Construction over Tank Top of Tanks #2 Regular 87 and#3 Super 91. <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge, the facts stated ht this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: � amene//Waeasa — Date: March 17,2011 <br /> —o o <br /> -� , <br /> 0 nnv <br />