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RECEIVE® <br /> SWRCB,January 2002 ANW a-20L— <br /> Secondary Containment Testing Report Form <br /> ENVIRONMENTAL <br /> This form is intended far use by contractors performing periodic testing of UST secondary containment sy�l /� �RTDhENT <br /> appropriate pages of thisform to report results all components tested. The completedform, written testp"roce ures, and <br /> printoutsfrom tests(ifapplicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: George's Mini Mart Date of Testing: April 19,2018 <br /> Facility Address: 18662 Hwy.88,Lockeford,Ca.95237 <br /> Facility Contact: Bill or Rupi Padla Phone: (209)727-3064 <br /> Date Local Agency Was Notified of Testing: 3/21/2018 <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#5246802-UT <br /> Credentials: X CSLB Licensed Contractor X SWRCB Licensed Tank Tester <br /> License Type: A License Number: CSLB Lie.#341375/SWRCB Lie.#90-1120 <br /> Manufacturer Trainine <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 Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> Annular Tank#I X ❑ ❑ ❑ Dispenser Sump#3&4 X ❑ ❑ ❑ <br /> Annular Tank#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 I ❑ ❑ ❑ Dispenser Sump#9s X ❑ ❑ ❑ <br /> Secondary Pipe#3 X ❑ ❑ ❑ 1 Dispenser Sump#1 Os X 1 ❑ ❑ ❑ <br /> Secondary Pipe#4 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 1 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <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 <br /> document are accurate and in full compliance with legal requirements <br /> Technician's Signature: e1sy �e1/ —x- Date: April 19.2018 <br />