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• <br /> SWRCB,January 2002 Page of <br /> — <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 testi(if applicable), should be provided to the facility ownerloperator for submittal to the local regulatory agency. <br /> 1, FACILITY LWORMATION <br /> Facility Name: RAI-Manteca.Arco I Date of Testing; October 20,2014 <br /> Facility Address: 1711 East Yosemite Ave.,Manteca,Ca.95336 <br /> Facility Contact; Amba Phone; (209)823-4715 <br /> Date Local Agency Was Notified of Testing: 10/17/2014,by Afford-A-Test <br /> Name of Local Agency Inspector(1f 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: 11 CSLB Licensed Contractor X SWRCB Licensed Tank Tester <br /> License Type: Tank Tester License Numbet:90-1120/ICC#5246802-UT <br /> ManufactmLgtTraining <br /> Manufacturer Com nent(s) Date Training E ties <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Repairs Component ass Fail l�1ot Repairs <br /> - Component pass Fail Tested Made P Tested I Made <br /> Annular Tank 41 X ❑ ❑ ❑ 0 ❑ ❑ ❑ <br /> Annular Tank#2 X ❑ ❑ 0 ❑ ❑ ❑ ❑ <br /> Annular Tank.43 X ❑ 2 ❑ 0 ❑ 0 ❑ <br /> Secondary Pipe 41 X ❑ ❑ ❑ ❑ 0 ❑ ❑ <br /> Secondary Pipe#2 X ❑ ❑ C ❑ 0 d ❑ <br /> Piping Sump#1 X ❑ ❑ ❑ ❑ ❑ ❑ 0 <br /> Piping Sump 42 X El 11 ❑ ❑ 0 0 <br /> Piping Sump #3 — X 0 ❑ ❑ ❑ 0 ❑ 0 <br /> Dispenser Sump#1&2 X 0 ❑ ❑ mo <br /> Dispenser Sump#3&4 X 0 ❑ 0 Dispenser Sump#5&6 X 0 ❑X D ❑ 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 beast of m1'knowledge,the.facts stated in this document are accurate and In full compliance with legal requirements <br /> Technician's Signature: J Date: October 20-2014 <br />