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SWRCB,January 2002 Page of <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: Delta Arco I Date of Testing: October 6,2011 <br /> Facility Address: 440 West Charter Way,Stockton,Ca.95206 <br /> Facility Contact: Major Singh I Phone: (209)465-2487 <br /> Date Local Agency Was Notified of Testing: 9/28/11 by Afford-A-Test <br /> Name of Local Agency Inspector(f present 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 45246802-UT <br /> Manufacturer Traininp, <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#1 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Annular Tank#2 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Secondary Pipe#I X 1 ❑ ❑ 1 ❑ ❑ ❑ ❑ ❑ <br /> Secondary Pipe#2 X ❑ ❑ ❑ ❑ ❑ ❑ 1 ❑ <br /> Piping Sump#1 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Piping Sump#2 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Dispenser Sump#1 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Dispenser Sump#2 X 1 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Dispenser Sump#3 X ❑ ❑ 1 ❑ ❑ ❑ ❑ ❑ <br /> Dispenser Sump#4 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ r� ❑ ❑ ❑ ❑ <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: Date: October 6,2011 <br />