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SWRCB,January 2002 RECEIf- <br /> Secondary Containment Testing Report ForffAN 16`2015 <br /> Thisform is intendedfor use by contractors performing periodic testing of UST secondary containment systems. Use the d <br /> appropriate pages of this form to report results far all components tested. The completed for <br /> printouts from tests(fopplicable), should be provided to the facility owner/operatorfor submi VI ICM ency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Wine Country 76 1 Date of Testing: December 23,2014 <br /> Facility Address: 1111 East Kettleman Lane,Lodi,Ca.95240 <br /> Facility Contact: Sandeep Singh I Phone: (209)369-3633 <br /> Date Local Agency Was Notified of Testing: 11/13/2014,by Afford-A-Test <br /> Name of Local Agency Inspector(ifpresent 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:90-1120/ICC#5246802-11T <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> Caldwell Systems Level Chane Indicator July, 2016 <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Not Repairs <br /> Component Pass Fail Tested Repairs <br /> Made Component Pass Fail Tested Made <br /> Annular Tank#1 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Annular Tank#2&3 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Secondary Pipe #] X ❑ ❑ ❑ 11 Ll El 11 <br /> Secondary Pipe#2 X Ll ❑ ❑ ❑ ❑ ❑ ❑ <br /> Secondary Pipe #3 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <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 /> Dispenser Sump#5&6 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Dispenser Sump#7&8 X I ❑ 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 by,R&D Compliance Testing. <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,the facts stated <br /> Ciinn"this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: .ifJ�rn ✓ �u� 'd Date: December 23,2014 <br />