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SWRCB,January 2002 Page of <br /> Secondary Containment Testing Report Form <br /> APR 2 M6 <br /> This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the s <br /> appropriate pages of this form to report results for all components tested. The completed form, written test 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: Plaza Liquors#I Date of Testing: March 16,2015 <br /> Facility Address: 800 South Cherokee Lane,Lodi,Ca. 95240 <br /> Facility Contact: Ashok Kumar I Phone: (209)368-0127 <br /> Date Local Agency Was Notified of Testing: 2/10/2015,by Afford-A-Test <br /> Name of Local Agency Inspector(tfpresent 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: 90-1120ACC#5246802-UT <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> Caldwell Systems Piping Sum s/UDC's July,2016 <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#1 X ❑ ❑ ❑ ❑ ❑ ❑ L <br /> Annular Tank#2&3 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Secondary Pipe#1 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Secondary Pipe#2 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Secondary Pipe#3 X 1 ❑ 1 ❑ ❑ ❑ I ❑ ❑ ❑ <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 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 11 11 El 11 El El Ll ❑ <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,the facts stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: nr6rce l/usrazn Date: March 16 2015 <br />