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l ' La Ya.+►.,l It ��- <br /> AUG 1 ?�16 <br /> SWRCB,January 2002 Page of <br /> Secondary Containment Testing Report Form <br /> This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the <br /> appropriate pages of this form to report results for all components tested. The completed form, written test procedures, and <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: Fast-n-Esy#16 1 Date of Testing: July 12,2016 <br /> Facility Address: 1399 East Yosemite Ave.,Manteca,Ca.95336 <br /> Facility Contact: Vikram I Phone: (559)213-0459 <br /> Date Local Agency Was Notified of Testing: 6/20/2016,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 T%pe: Tank Tester License Number: 90-1120/ICC#5246802-UT <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> Caldwell Systems Piping Sum s/UDC's July 31, 2017 <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> Secondary Pipe#1-87 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Secondary Pipe#2-Diesel X ❑ ❑ ❑ ❑ ❑ ❑ , ❑ <br /> Secondary Pipe#3-91 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Piping Sump#1-87 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Piping Sump#2-Diesel X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Piping Sump#3- 91 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 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <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 by,R&D Compliance Testing. <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.rull compliance with legal requirements <br /> Technician's Signature: .�i� �� L Date: July 12,2016 <br />