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SWRCB,January 2002 SECEIVEDPage_of_ <br /> Secondary Containment Testing Repol*'1016 <br /> This form is intended for use by contractors performing periodic testing of UST seconUWR�Medures, <br /> Use the <br /> appropriate pages of this form to report results for all components tested The completed)SR►q�}ySjE(qand <br /> printouts from tests(:f applicable),should be provided to the facility owner/operator for submitter"to thgulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: SUPER STORES INDUSTRIES I Date of Testing: 3-18-2016 <br /> Facility Address: 16888 MCKINLEY AVENUE,LAThIROP,CA 95330 <br /> Facility Contact: DOUG OR SCOTT Phone: (209)858-3384 <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(fpresent during testing): VICKIE MCCARTNEY <br /> 2. TESTING CONTRACTOR INFORMATION <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 Training Expires <br /> Caldwell Piping Sum /UDC's May,2019 <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Comonent Pass Fail Not Repairs <br /> p <br /> Tested Made Tested Made <br /> PIPING SUMP#I-DIESEL-WEST ® ❑ ❑ ® ❑ ❑ ❑ ❑ <br /> PIPING SUMP#2-DIESEL.-EAST g ❑ ❑ ® ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ I ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 11 El 11 11 11 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 /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,the f Wslaled.,,,this document are accurate and infull compliance with legal requirements <br /> Technician's Signature: Date: 3-18-2016 <br />