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RECEIVED <br /> SWRCB,January 2002 0 C T IM 24q of <br /> Secondary Containment Testing Report Form <br /> This form is intended for use by contractors performing periodic testing of UST secondary contaFvWAEEQNME_UT&_ HEALTH <br /> appropriate pages of this form to report results for all components tested. The completed form, written te[)EMWT#AFW <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: West Lane Chevron I Date of Testing: 9 132017 <br /> Facility Address: 4747 North West Lane,Stockton,Ca.95210 <br /> Facility Contact: Ravinder I Phone: (209)472-1639 <br /> Date Local Agency Was Notified of Testing: 8/8/2017 <br /> Name of Local Agency Inspector(if 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: X CSLB Licensed Contractor X SWRCB Licensed Tank Tester <br /> License Type: A I License Number: CSLB Lic.#341375/SWR('li I.ic.#90-1120 <br /> Manufacturer Trainin¢ <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#1-87 X ❑ ❑ ❑ Dispenser Sump#5&6 X ❑ ❑ ❑ <br /> Annular Tank#2-87 X ❑ ❑ ❑ Dispenser Sump#7&8 X ❑ ❑ ❑ <br /> Annular Tank#3-91 X 1 ❑ ❑ ❑ ❑ 1 ❑ ❑ ❑ <br /> Secondary Pipe#1-87 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Secondary Pipe #2-87 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Secondary Pipe#3-87 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Secondary Pipe#4-91 X ❑ ❑ ❑ ❑ ❑ 1 ❑ ❑ <br /> Piping Sump#1-87 X ❑ ❑ ❑ ❑ ❑ I ❑ ❑ <br /> Piping Sump#2-87 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Piping Sump#3-91 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Dispenser Sump#1&2 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Dispenser Sump#3&4 X <br /> El El EJ El El ❑ <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 fiull compliance with legal requirements <br /> Technician's Signature: W�enf � Date: September 13,2017 <br />