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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 thisform to report results for all components tested. The completedform, 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: SUPER STORES INDUSTRIES I Date of Testing: 9/12/2016 <br /> Facility Address: 16888 MCKINLEY AVENUE,LATHROP,CA 95330 <br /> Facility Contact: DOUG OR SCOTT I Phone: (209)858-3384 <br /> Date Local Agency Was Notified of Testing: 9/7/2016 SEEP <br /> Name of Local Agency Inspector(fpresent during testing): <br /> NUENIAL <br /> 2. TESTING CONTRACTOR INFORMATION PERMIT/S H111 <br /> Company Name: KAISER COMMERCIAL PETROLEUM <br /> Technician Conducting Test: GREG KAISER <br /> Credentials: ®CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester <br /> License Type: A License Number: 859535, ICC 5252318 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Trainina Ex ires <br /> Caldwell Piping Sum s/UDC's May,2019 <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> PIPING SUMP#I-DIESEL-WEST ® ❑ ❑ ® ❑ ❑ ❑ ❑ <br /> PIPING SUMP#2-DIESEL-EAST ® ❑ ❑ ® ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 11 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 KCP. <br /> NOTE: Per SR0073771 re-tested within 6 months of repair. <br /> CERTIFICATION OF TECCIA S RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,the st ed In this document are accurate and in full compliance with legal requirements <br /> / <br /> Technician's Signature: f Date: 9-12-2016 <br />