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V <br /> SWRCB,January 2002 " P9Be ZW of <br /> Secondary Containment Testing Report FCortmHEALTH <br /> This form is intended for use by contractors performing periodic testing of UST secondary contU+t77r A systems. Use the <br /> appropriate pages of this form to report results for all components tested The completed farm, written teist`procedures, and <br /> printouts from tests(ifapplicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Tesoro#68222 1 Date of Testing: May 10,2017 <br /> Facility Address: 2500 West Lodi Ave.,Lodi,Ca.95242 <br /> Facility Contact: Tonya Enos(Site Manager) Phone: (209)366-0703 <br /> Date Local Agency Was Notified of Testing: 5/8/2017,by Afford-a-test <br /> Name of Local Agency Inspector(ifpresent during testing): Aaron Hang,EHS <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:90-1120ACC#5246802-UT <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> Caldwell Systems Piping Sums July 30, 2017 <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 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Secondary Pipe#1-87 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Secondary Pipe#2-87 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Secondary Pipe#3-91 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Piping Sump#1-87 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Piping Sump#2-91 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <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 /> See comments page#3,of this report. <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge, <br /> the facts stated in thh�iss,document are accurate and in full compliance with legal requirements <br /> Technician's Signature: Date: May 10.2017 <br /> v <br />