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SWRCB, January 2002 <br />`y e-"AF71V1=D <br />j u Lagf T_M i <br />Secondary Containment Testing Report Form �N <br />This form is intendedfor use by contractors performing periodic testing of USTsecondary containment systV�D���TAL <br />appropriate pages of this form to report results for all components tested. The completed form, written t�w zlres, andT �� NT <br />printouts from tests (f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: GSG Gas & Mart I Date of Testing: June 27, 2018 <br />Facility Address: 701 East Charter Way, Stockton, Ca. 95206 <br />Facility Contact: Swaran Chouhan Phone: (209) 467-0305 <br />Date Local Agency Was Notified of Testing: 6/13/2018 <br />Name of Local Agency Inspector (f present during testing): <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: Afford -a -test <br />Pass Fail <br />Technician Conducting Test: Benjamin F. Duncan Jr. ACC #5246802 -UT <br />Credentials: X CSLB Licensed Contractor <br />X SWRCB Licensed Tank Tester <br />License Type: A <br />License Number: CSLB Lic. 4341375/SWRCB Lic. 1490-1120 <br />Manufacturer <br />Manufacturer Trainine <br />Component(s) Date Training Expires <br />Caldwell Systems <br />Piping Sum s/UDC's July 5, 2020 <br />❑ ❑ <br />Secondary Pipe #1 <br />X ❑ <br />❑ <br />❑ <br />❑ ❑ <br />3. SUMMARY OF TEST RESULTS <br />Component <br />Pass Fail <br />Not <br />Tested <br />Repairs <br />Made <br />Component pass Fail <br />Not Repairs <br />Tested Made <br />Annular Tank #1 &2 <br />X ❑ <br />❑ <br />❑ <br />❑ ❑ <br />❑ ❑ <br />Secondary Pipe #1 <br />X ❑ <br />❑ <br />❑ <br />❑ ❑ <br />❑ ❑ <br />Secondary Pipe #2 <br />X ❑ <br />❑ <br />❑ <br />❑ ❑ <br />❑ ❑ <br />Piping Sump #1 <br />X ❑ <br />❑ <br />❑ <br />❑ ❑ <br />❑ ❑ <br />Piping Sump #2 <br />X ❑ <br />❑ <br />❑ <br />❑ ❑ <br />❑ ❑ <br />Dispenser Sump #1 <br />X ❑ <br />❑ <br />❑ <br />❑ ❑ <br />❑ ❑ <br />Dispenser Sump #2 <br />X ❑ <br />❑ <br />❑ <br />❑ ❑ <br />❑ ❑ <br />Dispenser Sump #3 <br />X ❑ <br />❑ <br />❑ <br />❑ ❑ <br />❑ ❑ <br />Dispenser Sump #4 <br />X ❑ <br />❑ <br />❑ <br />❑ ❑ <br />❑ ❑ <br />❑ ❑ <br />❑ <br />❑ <br />❑ ❑ <br />❑ ❑ <br />❑ ❑ <br />❑ <br />❑ <br />❑ ❑ <br />❑ ❑ <br />❑ ❑ <br />❑ <br />EJ -11 <br />❑ ❑ <br />❑ ❑ <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: Date: Date: June 27, 2018 <br />