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T <br /> Page_of <br /> SWRCB,January 2002 <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(if applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Date of Testing: May 24,2017 <br /> Facility Name: MCM 14 AmPm <br /> Facility Address: 130 South Wilson Way,Stockton,Ca.95205 <br /> Facility Contact: Parminder Mashiana I Phone: (916)952-6337 <br /> Date Local Agency Was Notified of Testing: 4/7/2017,by Afford-A-Test <br /> Name of Local Agency Inspector(f 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: D 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 Expires <br /> Caldwell Systems Piping Sumps/Vent Box/UDC's/Fill Sums July 30,2017 <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Repairs Not Repairs <br /> Component Pass Fail Component Pass Fail Tested Made <br /> Tested Made <br /> Annular Tank#I X El El Piping Sump#3 X El El 11 <br /> Annular Tank#2 X El El Vent Box Sump X ❑ El ❑ <br /> Annular Tank#3 X ❑ ❑ ❑ Dispenser Sump#1&2 X ❑ ❑ ❑ <br /> Secondary Pipe#1 X 11 11 Dispenser Sump #3&4 X ❑ El ❑ <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 ❑ U Fill Riser Sump #3 X ❑ 0 D <br /> Secondary Pipe#7 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Piping Sump#1 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Piping Sump#2 X D D D ❑ ❑ ❑ ❑ <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: �G� ✓ � � Date: May 24,2017 <br />