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f <br />RECEIVED <br />S WRCB, January 2002 J U L U 8 ti 0 s t Page I of <br />Secondary Containment Testing Report Form <br />This form is intended for use by contractors performing IRe.NfltgA� HE secondary containment systems. Use the <br />I��FfR�fi� 1 tee.� <br />appropriate pages of this form to report results for all components teste . he completed form, written test procedures, and <br />printouts from tests (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: Wight Collins ARCO AmPm Date of Testing: May 18, 2011 <br />Facility Address: 130 South Wilson Way, Stockton, Ca. 95205 <br />Facility Contact: Lawrence Wight Phone: (209) 466-6633 <br />Date Local Agency Was Notified of Testing : 5/5/11 by Afford -A -Test <br />Name of Local Agency Inspector (rf 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 S W RCB Licensed Tank Tester <br />License Type: Tank Tester License Number: 90-1120/ICC #5246802 -UT <br />Manufacturer Training <br />Manufacturer Component(s) Date Training Expires <br />3. SUMMARY OF TEST RESULTS <br />Component <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />Component <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />Annular Tank #1 <br />X <br />❑ <br />❑ <br />❑ <br />Piping Sump #3 <br />X <br />❑ <br />❑ <br />❑ <br />Annular Tank #2 <br />X <br />❑ <br />❑ <br />❑ <br />Vent Box Sump <br />X <br />❑ <br />❑ <br />❑ <br />Annular Tank #3 <br />X <br />❑ <br />❑ <br />❑ <br />Dispenser Sump # 1 &2 <br />X <br />❑ <br />❑ <br />Secondary Pipe #1 <br />X <br />❑ <br />❑ <br />❑ <br />Dispenser Sump #3&4 <br />X <br />❑ <br />❑ <br />Secondary Pipe #2 <br />X <br />❑ <br />❑ <br />❑ <br />Dispenser Sump #5&6 <br />X <br />❑ <br />❑ <br />❑ <br />Secondary Pipe #3 <br />X <br />❑ <br />❑ <br />❑ <br />Dispenser Sump #7&8 <br />X <br />❑ <br />❑ <br />❑ <br />Secondary Pipe #4 <br />X <br />❑ <br />❑ <br />❑ <br />Fill Riser Sump #1 <br />X <br />❑ <br />❑ <br />❑ <br />Secondary Pipe #5 <br />X <br />❑ <br />❑ <br />❑ <br />Fill Riser Sump 42 <br />X <br />❑ <br />❑ <br />❑ <br />Secondary Pipe #6 <br />X <br />❑ <br />❑ <br />❑ <br />Fill Riser Sump #3 <br />X <br />❑ <br />❑ <br />G <br />Secondary Pipe #7 <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Piping Sump #1 <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Piping Sump #2 <br />X <br />❑ <br />❑ 1 <br />❑ <br />❑ <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 know/edge, the facts stated in this document are accurate and in -full compliance with legal requirements <br />Technician's Signature: es�ir�z��, ate: May 18. 2011 <br />