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r <br /> SWRCB,January 2002 Pae o of <br /> Secondary Containment Testing Report Form <br /> This form is intended for use by contractors performing periodic testing of LIST secondary containment systems. f s�the <br /> appropriate pages of this form to report results for all components tested The completed form, written test procedures, and <br /> printouts from tests(if applicable), should be provided to the facility owner/operator for submittal to the la� <br /> __ CTI i <br /> 1. FACILITY INFORMATION <br /> Facility Name: Alpha Fast Gas I Date of Testing: March 17,2015 <br /> Facility Address: 2358 East Waterloo Road,Stockton,Ca.95205 <br /> Facility Contact: John or Jimmy I Phone: (209)462-7502 <br /> Date Local Agency Was Notified of Testing: 211012015,by Afford-A-Test <br /> Name of Local Agency Inspector(if present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: R&D Compliance Testing <br /> Technician Conducting Test: Benjamin F. Duncan Jr. <br /> Credentials: I CSLB Licensed Contractor X SWRCB Licensed Tank Tester <br /> License Type: Tank Tester License Number: 90-1120AC(T524680241 <br /> Manufacturer Traminji <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#I X ❑ ❑ ❑ Dispenser Sump#7&8 X ❑ ❑ 7 <br /> Annular Tank#2 X ❑ ❑ ❑ ❑ ❑ ❑ —1 <br /> Annular Tank 43 X ❑ ❑ ❑ ❑ ❑ ❑ <br /> Secondary Pipe#I X ❑ ❑ ❑ ❑ ❑ ❑ C <br /> Secondary Pipe#2 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Secondary Pipe #3 X ❑ ❑ 11 ❑ ❑ ❑ ❑ <br /> Piping Sump#1 X ❑ ❑ ❑ ❑ ❑ ❑ <br /> Piping Sump#2 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Piping Sump #3 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Dispenser Sump 41&2 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Dispenser Sump 43&4 X ❑ ❑ ❑ ❑ ❑ ❑ LI <br /> Dispenser Sump 45&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,the facts stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: .►zyaytzvarzcrL Date: March 17,2015 <br />