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6RECEIVED <br /> SWRCB,January 2002 OC Pagel Z01of_ <br /> Secondary Containment Testing Report FoEWIRONMENTAL HEALTH <br /> This farm is intended for use by contractors performing periodic testing of UST secondary containment systDEPARWENT <br /> appropriate pages of this form to report results for all components tested The completed form, written testprocedures, 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: Kwik&Easy Food Mart I Date of Testing: October 11,2016 <br /> Facility Address: 824 East Yosemite Ave.,Manteca,Ca.95226 <br /> Facility Contact: Jit Singh I Phone: (209)823-8800 <br /> Date Local Agency Was Notified of Testing: 9/29/2016,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 Type: Tank Tester License Number: 90-1120/ICC#5246802-UT <br /> Manufacturer Trainina <br /> Manufacturer Component(s) Date Training Expires <br /> Caldwell Systems Piping Sum s/UDC's July 30, 2017 <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Hail Not Repairs <br /> Tested Made Tested Made <br /> Annular Tank#1 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Annular Tank#2&3 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Secondary Pipe#1 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Secondary Pipe#2 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Secondary Pipe#3 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Piping Sump#1 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Piping Sump#2 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Piping Sump#3 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Dispenser Sump#1&2 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Dispenser Sump#3&4 X L1El ❑ ❑ El ❑ <br /> Dispenser Sump#5&6 X ❑ ❑ ❑ ❑ El ❑ ❑ <br /> Dispenser Sump#7&8 X ❑ ❑ 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 /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,Jthe facts stated in this document area accurate and in full compliance with legal requirements <br /> Technician's Signature: .�tib>rssos�slis --qr n —,d. Date: October 11,2016 <br />