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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 /> F;; <br /> Stop N Shop Date of Testing: January 18,2017 <br /> s: 1856 Country Club Blvd., Stockton,Ca.95206 <br /> t: Harwinder Bhatia(Sonny) Phone: (209)222-2220 <br /> ency Was Notified of Testing: 1/3/2017,by Afford-A-Test <br /> 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: 11CSLB Licensed Contractor X SWRCB Licensed Tank Tester <br /> License Number: 90-1120/ICC#5246802-UT <br /> License Type: Tank Tester <br /> Manufacturer Training <br /> Manufacturer Com onent(s) Date Training Ex ires <br /> Caldwell Systems Piping Sumps/UDC's July30, 2017 <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Repairs Pass Fail Not Repairs <br /> C <br /> omponent Pass Fail Component Tested Made <br /> Tested Made <br /> #1&2 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> e#1 X ❑ ❑ ❑e #2 ❑ ❑ ❑1 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Piping Sump#2 X ❑ El [I ❑ ❑ ❑ <br /> Dispenser Sump #1&2 X 11 ❑ ❑ ❑ El ❑ <br /> [� <br /> Dispenser Sump#3&4 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> El❑ ❑ ❑ ❑ ❑ ❑ <br /> El <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> El El <br /> ❑ <br /> If hydrostatic testing was performed,describe what was done with the water aft77 - <br /> c Enof tests: <br /> Test Fluid Supplied and recovered for reuse by,R&D Compliance Testing. <br /> Wf <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR COI 1 '� 4 7W <br /> i4 . <br /> To the best of my knowledge,the facts stated in this document are accurate and in full complianc wkt�t l i requirements <br /> Technician's Signature, ffo / fa !!5;ox Date: January 18 2017 <br />