Laserfiche WebLink
RECEIVED <br /> SWRCB,January 2002 OCT ftM of_ <br /> Secondary Containment Testing Report Form bb LOiI <br /> This form is intended for use by contractors performing periodic testing of UST secondary conE"QkAE NTA&G HEALTH <br /> appropriate pages ofthis form to report results for all components tested. The completedform, written 1)EprAjgtENl <br /> printouts from tests(if applicable), should be provided to the facility owner/operator for submittal to the local regu at, agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Jahant Food-N-Fuel Stop Date of Testing: 9/21/2017 <br /> Facility Address: 24323 North Hwy 99,Acampo,Ca.95220 <br /> Facility Contact: Bachitar Singh I Phone: (209)333-6000 <br /> Date Local Agency Was Notified of Testing: 8/31/2017 <br /> Name of Local Agency Inspector(ifpreseni during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Com anName: Afford-a-test <br /> Technician Conducting Test: Benjamin F.Duncan Jr./ICC#5246802-UT <br /> Credentials: X CSLB Licensed Contractor X SWRCB Licensed Tank Tester <br /> License Type: A License Number: CSLB Lic.#341375/SWRCB Lic.490-1120 <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#1,2,&3 X ❑ ❑ ❑ Dispenser Sump#5&6 X ❑ ❑ ❑ <br /> Annular Tank#4 X ❑ ❑ ❑ Dispenser Sump#7&8 X ❑ ❑ ❑ <br /> Secondary Pipe #1 X ❑ ❑ ❑ Dispenser Sump#9&10 X ❑ ❑ ❑ <br /> Secondary Pipe#2 X ❑ ❑ ❑ Dispenser Sump#11&12 X ❑ ❑ ❑ <br /> Secondary Pipe #3 X ❑ ❑ ❑ Dispenser Sump#13&14 X ❑ ❑ ❑ <br /> Secondary Pipe#4 X ❑ ❑ ❑ Dispenser Sump#15&16 X ❑ ❑ ❑ <br /> Piping Sump#1 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Piping Sump#2 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Piping Sump#3 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Piping Sump#4 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Dispenser Sump#1&2 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Dispenser Sump#3&4 X ❑ ❑ 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 thhi/iss�document are accurate and in full compliance with legal requirements <br /> �.61Y> <br /> Technician's Signature: f�� _I/ Date: September 21.2017 <br />