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SWRCB, January 2002 <br />., <br />REEIVEE <br />Page _ of _ <br />Secondary Containment Testing Report Form APR 14 2015 <br />This form is intended for use by contractors performing periodic testing of UST secondary containmentsytENTAL <br />appropriate pages ofthisform to report resultsfor all components tested The completedform, written tes pr�q noT��e��T <br />printouts from tests (f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: Pershing Gas I Date of Testing: 11/19/2014 <br />Facility Address: 4445 North Pershing Ave., Stockton, Ca. 95207 <br />Facility Contact: Cheema I Phone: (209) 477-8004 <br />Date Local Agency Was Notified of Testing: 10/20/2014, by Afford -A -Test <br />Name of Local Agency Inspector (if present during testing): <br />2- TESTING CONTRACTOR INFORMATION <br />Company Name: <br />R&D Compliance Testing <br />Technician Conducting Test: Benjamin F. Duncan Jr. <br />Credentials: <br />CSLB Licensed Contractor X SWRCB Licensed Tank Tester <br />License Type: <br />Tank Tester License Number: 90-1120/ICC #5246802 -UT <br />Manufacturer <br />In <br />Manufacturer Training <br />Component(s) Date Training Expires <br />Secondary Pipe #1 <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />3. SUMMARY OF TEST RESULTS <br />Component <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs Component <br />Made <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />Secondary Pipe #1 <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Secondary Pipe #2 <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Secondary Pipe #3 <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Piping Sump #1 <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Piping Sump #2 <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Piping Sump #3 <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Dispenser Sump #1&2 <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Dispenser Sump #3&4 <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Dispenser Sump #5&6 <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />1 ❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />I ❑ <br />❑ <br />❑ <br />❑ <br />❑ <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 document are accurate and in full compliance with legal requirements <br />Technician's Signature: ,�.qr"-g � Date: November 19. 2014 <br />