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SWRCB, January 2002ge of r') <br />Secondary Containment Testing Report Form 0 i 2011 <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 regulatoiy agencv. <br />I- FA( i.iTV 1NFnRMAT1nN <br />Facility Name: Food Mart Gasoline I Date of Testing: 11/30/2010 <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: 11/23/10 by Afford -A -Test <br />Name of Local Agency Inspector (ifpresent during testing): <br />.=N0611110109KIl►M■raymr2l:a1►1IrelN►lRIV11r8W <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 <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 />L <br />Secondary Pipe #1 <br />X <br />❑ <br />❑ <br />❑ <br />Fill Riser Sump #3 <br />X <br />❑ <br />❑ <br />❑ <br />Secondary Pipe #2 <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Secondary Pipe #3 <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Piping Sump #1 <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Piping Sump #2 <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Piping Sump #3 <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Dispenser Sump #1&2 <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Dispenser Sump #3&4 <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Dispenser Sump #5&6 <br />X <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 fidl compliance with legal requirements <br />Technician's Signature: Date: November 30, 2010 <br />