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RECEIVED <br /> SWRCB,January 2002 SES Page�7of <br /> Secondary Containment Testing Report Form �� <br /> This form is intended for use by contractors performing periodic testing of UST secondary contcfif VA)iPr EWi f HEALTH <br /> appropriate pages of this form to report results for all components tested. The completed form, written tE) <br /> printouts from tests(if applicable), should be provided to the facility owner/operator for submittal to the local gu�11 ency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: J&L Market I Date of Testing: August 16,2017 <br /> Facility Address: 8115 South EI Dorado Street,French Camp,Ca.95231 <br /> Facility Contact: Randy or Eugenia I Phone: (209)982-0897/Cell#(209)649-9660 <br /> Date Local Agency Was Notified of Testing: 7/11/2017 <br /> Name of Local Agency Inspector(f present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Afford-a-test <br /> Technician Conducting Test: Benjamin F.Duncan Jr./ICC#5246802-UT <br /> Credentials: CSLB Licensed Contractor X SWRCB Licensed Tank Tester <br /> License Type: A License Number: CSLB Lic.#341375/SWRCB Lic.#90-1120 <br /> Manufacturer Trainine <br /> Manufacturer Component(s) Date Training Expires <br /> Caldwell Systems Piping Sum s/UDC's July 5,2020 <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 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Annular Tank#2&3 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Secondary Pipe#1 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Secondary Pipe#2 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Secondary Pipe#3 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Piping Sump#1 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Piping Sump#2 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Piping Sump#3 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Dispenser Sump#1&2 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Dispenser Sump#3&4 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Dispenser Sump#5&6 X ❑ ❑ ❑ 1 ❑ ❑ ❑ ❑ <br /> Dispenser Sump#7&8 X ❑ ❑ ❑ 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. <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: <.O� as�urr. J` �� Date: August 16,2017 <br />