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0 0 REC <br />SWRCB, January 2002 Fag��t<.! <br />Secondary Containment Testing Report FormOCT 16 2014 <br />This farm is intended for use by contractors performing periodic testing of UST secondary (tems. Use the <br />appropriate pages of this form to report results for all components tested The completed form; M",W I T <br />printoutsfrom tests (if applicable), should be provided to the facility owner/operatorfor submittal tD&Rikf{7yg&0 agtgcp <br />1. FACILITY INFORMATION <br />Facility Name: Ernie's General Store I Date of Testing: 9/29/2014 <br />Facility Address: 4407 East Waterloo Rd., Stockton, Ca. 95215 <br />Facility Contact: Ernie Giannecchini I Phone: (209) 931-2850 <br />Date Local Agency Was Notified of Testing: 9/24/2014, 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: ❑ CSLB Licensed Contractor X SW RCB Licensed Tank Tester <br />License Type: Tank Tester License Number: 90-1120/ICC #5246802 -UT <br />Manufacturer Training <br />Manufacturer Component(s) Date Fraining Expi <br />3. SUMMARY OF TEST RESULTS <br />Component <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />Component <br />Pass <br />Fail <br />Not <br />I Tested <br />Repairs <br />Made <br />Annular Tank #1 <br />X <br />❑ <br />❑ <br />❑ <br />Dispenser Sump #9&10 -RT <br />X <br />❑ <br />❑ <br />❑ <br />Annular Tank #2&3 <br />X <br />❑ <br />❑ <br />❑ <br />Dispenser Sump #1&2 -CL <br />X <br />❑ <br />❑ <br />❑ <br />Secondary Pipe #1 <br />X <br />❑ <br />❑ <br />❑ <br />Dispenser Sump #3&4 -CL <br />X <br />❑ <br />❑ <br />❑ <br />Secondary Pipe #2 <br />X <br />❑ <br />❑ <br />❑ <br />Dispenser Sump #5&6 -CL <br />X <br />❑ <br />❑ <br />❑ <br />Secondary Pipe #3 <br />X <br />I ❑ <br />I ❑ <br />❑ <br />1 Dispenser Sump #7&8 -CL <br />X <br />❑ <br />❑ <br />❑ <br />Piping Sump #1 <br />X <br />I ❑ <br />❑ <br />❑ <br />Dispenser Sump 9&10 -CL <br />X <br />❑ <br />❑ <br />❑ <br />Piping Sump #2 <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />1 ❑ <br />Piping Sump #3 <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Dispenser Sump #1&2 -RT <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Dispenser Sump #3&4 -RT <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Dispenser Sump #5&6 -RT <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Dispenser Sump #7&8 -RT <br />X <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 />Test Fluid Supplied and recovered for reuse by, R&D Compliance Testing. <br />RT=Retail Island/CL—Card Lock Island. <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: i1ir �q ffr4 aali� Date: September 29, 2014 <br />