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SWRC$,January 2002 0 0 Page of <br /> Secondary Containment Testing Report FornPECEIVED <br /> This form is intended for use by contractors performing periodic testing of UST secondary containment syst U th <br /> appropriate pages of this form to report results for all components tested. The completed form, written test r s, <br /> printouts from tests(tf applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> HEALTH <br /> 1. FACILITY INFORMATION ENVIRONMENTAL <br /> @ kiAAl° r�-10-,2711 <br /> /i <br /> Facility Name: San Joaquin County Corp.Yard Date of Testing: January 19,2 l 1 <br /> Facility Address: 1810 East Hazelton Ave.,Stockton,Ca. 95203 <br /> Facility Contact: Dave Bylow I Phone: (209)468-3105 <br /> Date Local Agency Was Notified of Testing: 1/11/11 by Afford-A-Test <br /> Name of Local Agency Inspector(if 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: 0 CSLB Licensed Contractor X SWRC13 Licensed Tank Tester <br /> License Type: Tank Tester License Number: 90-1120/ICC#:5246802-UT <br /> Manufacturer Training <br /> Manufacturer Com onent(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 /> Piping Sump#1 X 1 ❑ ❑ ❑ 1 ❑ ❑ ❑ <br /> Piping Sump #2 X ❑ ❑ ❑ ❑ ❑ ❑ <br /> 0 ❑ 0 0 0 ❑ <br /> 0 0 ❑ ❑ 0 ❑ <br /> 0 0 0 ❑ ❑ ❑ <br /> ❑ ❑ ❑ 0 ❑ ❑ <br /> ❑ 0 ❑ ❑ 0 0 ❑ <br /> ❑ 0 ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ 0 ❑ 0 ❑ ❑ <br /> ❑ 1 ❑ 1 0 ❑ ❑ ❑ ❑ <br /> d� <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: rffW Mr1, Date: Januay 19,2011 <br />