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f-1 J21 <br /> SWRC9,January 2002 Page 11' of <br /> Secondary Containment Testing Report ForlRECEIVED <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 to ®rrc�ec}�rond <br /> printouts from tests(f applicable), should be provided to the facility owner/operator for submittal to the Iota regulatory agency. <br /> 1. FACILITY INFORMATION EWRONME <br /> Facility Name: Marigold Shell I Date of Testing: -PERMlTfflJWfW2010 <br /> Facility Address: 6131 Pacific Ave.,Stockton,Ca. 95207 <br /> Facility Contact: Hung Tran I Phone: (209)9524862 <br /> Date Local Agency Was Notified of Testing: 8/18/2010 by Afford-A-Test <br /> r <br /> me 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 I License Number:90-1 120/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 /> Secondary Pipe#1 X ❑ ❑ ❑ ❑ ❑ 0 <br /> Secondary Pipe#2 X ❑ ❑ ❑ 0 ❑ 0 <br /> Secondary Pipe#3 X ❑ 1 0 0 1 ❑ 0 ❑ <br /> Piping Sump#1 X ❑ ❑ ❑ ❑ 0 0 <br /> Piping Sump#2 X ❑ ❑ ❑ 0 0 ❑ <br /> Piping Sump#3 X ❑ ❑ ❑ 0 0 0 <br /> Dispenser Sump#1&2 X ❑ ❑ ❑ ❑ 0 0 <br /> Dispenser Sump#3&4 X ❑ ❑ ❑ _ ❑ 0 0 ❑ <br /> Dispenser Sump# 5&6 X ❑ ❑ ❑ ❑ ❑ 0 0 <br /> Dispenser Sump #7&8 X ❑ ❑ ❑ 0 0 0 0 <br /> 0 0 0 0 ❑ ❑ ❑ <br /> 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: tDate: <br /> � � <br />