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RECEIVED <br /> SWRCB,January 2002 Page of <br /> Secondary Containment Testing Report FormJUN 19 2014 <br /> This form is intended for use by contractors performing periodic testing of UST secondary c inmer�I systems. Use ett LT H <br /> appropriate pages of this form to report results for all components tested. The completed fo Wt� <br /> printouts from tests(f applicable), should be provided to the facility owner/operator for submittal to LaLR�RT#Mwagency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Rainbow AmPm I Date of Testing: May 28, 2014 <br /> Facility Address: 130 South Wilson Way, Stockton,Ca.95205 <br /> Facility Contact: Parmjit Phone: (916)416-4743 <br /> Date Local Agency Was Notified of Testing: 5/14/2014,by Afford-A-Test <br /> Name of Local Agency Inspector(if present 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-UT <br /> Manufacturer Training <br /> Manufacturer Com onent(s) Date Training Expire <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 ❑ ❑ G Piping Sump#3 X ❑ ❑ ❑ <br /> Annular Tank#2 X ❑ ❑ ❑ Vent Box Sump X ❑ ❑ ❑ <br /> Annular Tank#3 X ❑ ❑ ❑ Dispenser Sump 41&2 X ❑ ❑ ❑ <br /> Secondary Pipe #1 X ❑ ❑ ❑ Dispenser Sump#3&4 X ❑ ❑ ❑ <br /> Secondary Pipe #2 X ❑ ❑ ❑ Dispenser Sump#5&6 X ❑ ❑ ❑ <br /> Secondary Pipe#3 X ❑ ❑ ❑ Dispenser Sump#7&8 X ❑ ❑ ❑ <br /> Secondary Pipe#4 X ❑ ❑ ❑ Fill Riser Sump#1 X ❑ ❑ ❑ <br /> Secondary Pipe#5 X ❑ ❑ ❑ Fill Riser Sump#2 X ❑ ❑ ❑ <br /> Secondary Pipe#6 X ❑ ❑ ❑ Fill Riser Sump#3 X ❑ ❑ ❑ <br /> Secondary Pipe#7 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Piping Sump#1 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Piping Sump#2 X ❑ C' 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 in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: Zwam� ��ttnoasy� Date: May 28,2014 <br />