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SWRCB, January 2002 Page of Secondary Containment Testing Report Form This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the appropriate pages of this form to report results for all components tested. The completed form, written test procedures, and printouts from tests (f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. FACILITY INFORMATION Facility Name: Flame Liquor & Gas Date of Testing: 11/17/2011 Facility Address: 1301 West Kettleman Lane, Lodi, Ca. 95242 Facility Contact: Rupi I Phone: (209) 334-3233 Date Local Agency Was Notified of Testing: 10/24/11 by Afford -A -Test -11/16/11 for date change Name of Local Agency Inspector (fpresent during testing): 2. TESTING CONTRACTOR INFORMATION Company Name: R&D Compliance Testing Technician Conducting Test: Benjamin F. Duncan Jr. Credentials: ❑ CSLB Licensed Contractor X SWRCB Licensed Tank Tester License Type: Tank Tester License Number: 90-1120/ICC #5246802 -UT Manufacturer Training Manufacturer Component(s) Date Training Expires If hydrostatic testing was performed, describe what was done with the water after completion of tests: Test Fluid Supplied and recovered for reuse by, R&D Compliance Testing. Note: Original test date of 11/21/2011, changed to 11/17/2011. Ok per Local CUPA. CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING To the best of my knowledge, the facts stated in this document are accurate and in full compliance with legal requirements Technician's Signature:Wyyawff��iaJr Date: November 17, 2011 3. SUMMARY OF TEST RESULTS Component Pass Fail Tested Not Repairs Made Component Pass Fail Not Tested Repairs Made Annular Tank #I X ❑ ❑ ❑ ❑ ❑ ❑ ❑ Annular Tank #2&3 X ❑ ❑ 0 ❑ ❑ ❑ ❑ Secondary Pipe #I X ❑ 0 ❑ ❑ 1 0 ❑ 0 Secondary Pipe #2 X ❑ ❑ ❑ ❑ ❑ ❑ 1 ❑ Secondary Pipe #3 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ Piping Sump #1 X ❑ ❑ ❑ 0 0 ❑ ❑ Piping Sump #2 X ❑ ❑ ❑ ❑ 1 ❑ ❑ ❑ Piping Sump #3 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ Dispenser Sump # 1 &2 X ❑ ❑ ❑ ❑ 0 0 ❑ Dispenser Sump #3&4 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ Dispenser Sump #5&6 X 1 ❑ ❑ ❑ 1 ❑ ❑ ❑ ❑ Dispenser Sump #7&8 X I ❑ ❑ ❑ I I ❑ ❑ ❑ ❑ If hydrostatic testing was performed, describe what was done with the water after completion of tests: Test Fluid Supplied and recovered for reuse by, R&D Compliance Testing. Note: Original test date of 11/21/2011, changed to 11/17/2011. Ok per Local CUPA. CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING To the best of my knowledge, the facts stated in this document are accurate and in full compliance with legal requirements Technician's Signature:Wyyawff��iaJr Date: November 17, 2011