Laserfiche WebLink
0 18 RECEIVED <br /> SWRCB,January 2002 Page of <br /> Secondary Containment Testing Report Form AP's 11 2014 <br /> This form is intended for use by contractors performing periodic testing of UST secondary containmen <br /> appropriate pages of this form to report results for all components tested. The completed form, written Re4gMWAFLETAAT NT <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: Benjamin Holt Arco I Date of Testing: March 28,2014 <br /> Facility Address: 2908 Benjamin Holt Drive,Stockton,Ca.95207 <br /> Facility Contact: Lawrence Wight Phone: (209)478-5552 <br /> Date Local Agency Was Notified of Testing: 3/20/2014,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: P,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 Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> Annular Tank#1 X ❑ ❑ ❑ Transition Piping Sump X ❑ ❑ ❑ <br /> Annular Tank#2 X ❑ ❑ ❑ Vapor Pot Sump X ❑ ❑ ❑ <br /> Annular Tank#3 X ❑ ❑ ❑ Dispenser Sump#1&2 X ❑ ❑ ❑ <br /> Secondary Pipe#1 X ❑ ❑ ❑ Dispenser Sump#3&4 X ❑ ❑ ❑ <br /> Secondary Pipe #2 X ❑ ❑ ❑ Dispenser Sump#5&6 X ❑ ❑ ❑ <br /> Secondary Pipe #3 X ❑ ❑ ❑ Dispenser Sump#7&8 X ❑ ❑ ❑ <br /> Secondary Pipe #4 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Secondary Pipe #5 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Secondary Pipe #6 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Piping Sump#1 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Piping Sump#2 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Piping Sump#3 X El ❑ ❑ El 11 !E] <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: s'ra � Date: March 28,2014 <br />