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t ' <br /> SWRCB,January 2002 Page 1 ofP) <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: Arco AmPm Date of Testing: September 1,2011 <br /> Facility Address: 1100 South Main St.,Manteca,Ca.95337 <br /> Facility Contact: Kul Sharma I Phone: (510)468-2371 <br /> Date Local Agency Was Notified of Testing: 8/29/11 <br /> Name of Local Agency Inspector(fpresent 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 Component(s) Date Training Expires <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 ❑ ❑ ❑ Dispenser Sump#7&12 X ❑ ❑ ❑ <br /> Annular Tank#2 X ❑ ❑ ❑ Dispenser Sump#8&11 X ❑ ❑ 0 <br /> Annular Tank#3 X ❑ 0 0 Dispenser Sump#9&10 X ❑ ❑ ❑ <br /> Secondary Pipe#1 X ❑ ❑ ❑ Fill Riser Sump#1 X ❑ ❑ ❑ <br /> Secondary Pipe#2 X ❑ ❑ ❑ Fill Riser Sump#2 X ❑ ❑ ❑ <br /> Secondary Pipe #3 X ❑ ❑ ❑ Fill Riser Sump#3 X ❑ ❑ ❑ <br /> Piping Sump#1 X ❑ 0 0 0 0 ❑ <br /> Piping Sump #2 X ❑ ❑ ❑ 0 0 0 <br /> Piping Sump#3 X ❑ 0 0 0 0 ❑ ❑ <br /> Dispenser Sump#1&6 X ❑ ❑ ❑ 0 0 0 ❑ <br /> Dispenser Sump#2&5 X ❑ ❑ 0 0 0 0 0 <br /> Dispenser Sump#3&4 X 0 0 0 0 0 0 ❑ <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: y � Date: Seotember 1,2011 <br />