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SWRCB, January 2002 <br />RECEIVED <br />S Ealf "Y4 <br />Secondary Containment Testing Report Form <br />NVII�r,n9i�;1-i.�LTF <br />This form is intended for use by contractors performing periodic testing of UST secondary containment sys e �s.� Ret e <br />appropriate pages of this form to report results for all components tested The completed form, written test �-E'c��ur��a NT <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: Food Mart Gasoline Date of Testing: 11/21/2013 <br />Facility Address: 2185 East Fremont St, Stockton, Ca. 95205 <br />Facility Contact: Joginder Lal I Phone: (209) 547-1700 <br />Date Local Agency Was Notified of Testing: 10/24/13, by Afford -A -Test <br />Name of Local Agency Inspector (if present during testing): <br />2. TFSTING 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_ STTMMARY 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 #1,2&3 <br />X <br />❑ <br />❑ <br />❑ <br />Fill Riser Sump #2 <br />X <br />❑ <br />❑ <br />❑ <br />Secondary Pipe #1 <br />X <br />❑ <br />❑ <br />❑ <br />Fill Riser Sump #3 <br />X <br />❑ <br />❑ <br />❑ <br />Secondary Pipe 42 <br />X 1 <br />❑ <br />❑ <br />1 ❑ <br />❑ <br />1 ❑ <br />❑ <br />1 ❑ <br />Secondary Pipe #3 <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />1 ❑ <br />❑ <br />❑ <br />Piping Sump #1 <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Piping Sump #2 <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Piping Sump #3 <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Dispenser Sump #1&2 <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Dispenser Sump #3&4 <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Dispenser Sump #5&6 <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Dispenser Sump #7&8 <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Fill Riser Sump #1 <br />X <br />❑ <br />❑ <br />❑ <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 knowledge, the facts stated in this document are accurate and in full compliance with legal requirements <br />Technician's Signature: 1 y& I . Date: November 21, 2013 <br />