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RECEIVED <br /> SWRCB,January 2002 APR daje 2018 of_ <br /> Secondary Containment Testing Report Form ENVIRONMENTAL <br /> This form is intendedfor use by contractors performing periodic testing of UST secondary containmejW s5WaV.rl R4FbP4F.NT <br /> appropriate pages of this form to report results far all components tested The completedform, written testprocedures, and <br /> printoutsfrom tests(ifopplicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Plaza Liquors#1 I Date of Testing: March 13, 2018 <br /> Facility Address: 800 South Cherokee Lane,Lodi,Ca. 95240 <br /> Facility Contact: Govinder Atwal or Raj (Son) Phone: (209)368-0127 <br /> Date Local Agency Was Notified of Testing: 2/13/2018 <br /> Name of Local Agency Inspector(ifpresent during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Afford-a-test <br /> Technician Conducting Test: Benjamin F.Duncan Jr./ICC 45246802-UT <br /> Credentials: X CSLB Licensed Contractor X SWRCB Licensed Tank Tester <br /> License Type: A License Number: CSLB Lic.#341375/SWRCB Lic.#90-1120 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> Caldwell Systems Piping Sum s/UDC's July 5,2020 <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 /> 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 1 ❑ ❑ ❑ ❑ ❑ ❑ 1 ❑ <br /> Piping Sump 41 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 /> ❑ 1 ❑ ❑ I ❑ ❑ I ❑ ❑ ❑ <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. <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: MMslla 9mverrss,,,,k Date: March 13.2018 <br />