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1 <br /> 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 cont inment 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(i(applicable),should be provided to the facility owner/operator.for submi al to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Jesse&Kul Petroleum Arco •a -of jesting: June 8,2017 <br /> Facility Address: 1711 East Yosemite Ave.,Manteca,Ca.95336 - <br /> Facility Contact: Jesse I Phone: (209)8 5-6784 <br /> Date Local Agency Was Notified of Testing: 6/6/2017,by Afford-6Z 117 z / <br /> Name of Local Agency Inspector(if present during testing: <br /> ENVIRONMENTAL HEALTH <br /> 2. <br /> - <br /> 2. TESTING CONTRACTOR INFORMATION DEPARTMENT <br /> Company Name: R&D Compliance Testing <br /> Technician Conducting Test: Benjamin F.Duncan Jr. <br /> Credentials: CSLB Licensed Contractor X SWRCB Licensed Tank T ster <br /> License Type: Tank Tester License Number: 90-1120/ICC#5246802-UT <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> Caldwell Systems Piping Sum s/UDC's July 30, 2017 <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Repairs Not Repairs <br /> Component Pass Fail Tested Made Component Pass Fail Tested Made <br /> Annular Tank#1 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Annular Tank#2 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Annular Tank#3 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Secondary Pipe #I X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Secondary Pipe #2 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Piping Sump#1 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Piping Sump#2 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Piping Sump#3 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Dispenser Sump#1&2 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Dispenser Sump#3&4 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Dispenser Sump#5&6 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Dispenser Sump#7&8 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <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 /> 074rTechnician's Signature- �� 2 Date: June 8,2017 <br />