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U S%.e <br /> SWRCB,January 2002 Page_of <br /> Secondary Containment Testing Report Form <br /> This form is intended for 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 completedform, 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 /> 1. FACILITY INFORMATION <br /> Facility Name: River Point Landing Marina I Date of Testing: February 23,2015 <br /> Facility Address: 4950 Buckley Cove Way, Stockton,Ca.95201 <br /> Facility Contact: Andrew Rehberg Phone: (209)951-4144 <br /> Date Local Agency Was Notified of Testing: 1/15/2015,by Afford-A-Test <br /> Name of Local Agency Inspector(rfpresent 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 INNEEN <br /> Manufacturer Component(s) Date Train;. Ex ires <br /> Caldwell Systems Piping Sums 1111v 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 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Annular Tank#2 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Secondary Pipe #1 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Secondary Pipe#2 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Piping Sump#1 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Piping Sump#2 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Dispenser Sump#1&2 ❑ ❑ *X ❑ ❑ ❑ ❑ ❑ <br /> Dispenser Sump#3&4 ❑ ❑ *X ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> El El El fE <br /> ❑El [I El ❑ ❑ ❑ ❑ <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 5 of this report for Dispenser Sumps/UDC's. <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,the facts statedin this <br /> document are accurate and in full compliance with legal requirements <br /> Technician's Signature: . jLr2v, t Date: February 23.2015 <br />