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• RECEIVEb <br /> SWRCB,January 2002 Page of <br /> Secondary Containment Testing Report Form {r�� MAY 0 8 2015 <br /> This form is intended for use by contractors performing periodic testing of UST secondary containment systeFENVI O N MENTAL. <br /> appropriate pages of this form to report results for all components tested The completed form, written lest pro66ffd ,1-tmefoi ore A�k', <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: George's Mini Mart Date of Testing: April 23,2015 <br /> Facility Address: 18662 Hwy. 88,Lockeford,Ca.95237 <br /> Facility Contact: Bill or Rupi Padla Phone: (209)727-3064 <br /> Date Local Agency Was Notified of Testing: 3/10/2015,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 T)pe: 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#3&4 X ❑ ❑ ❑ <br /> Annular Tank#2&3 X ❑ ❑ ❑ Dispenser Sump#5&6 X ❑ ❑ ❑ <br /> Annular Tank#4 X ❑ ❑ ❑ Dispenser Sump #7&8 X ❑ ❑ ❑ <br /> Secondary Pipe #1 X ❑ ❑ ❑ Dispenser Sump#9&10 X ❑ ❑ ❑ <br /> Secondary Pipe#2 X ❑ ❑ ❑ Dispenser Sump #9s X ❑ ❑ ❑ <br /> Secondary Pipe #3 X ❑ ❑ ❑ Dispenser Sump#1 Os X ❑ ❑ ❑ <br /> Secondary Pipe #4 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Piping Sump#1 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Piping Sump#2 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Piping Sump#3 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Piping Sump#4 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Dispenser Sump#1&2 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 in this <br /> document are accurate and in full compliance with legal requirements <br /> Technician's Signature: min -gr Date: April 23,2015 <br />