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SWRCB, January 2002 <br />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 />Facility Name: SMK/Kettleman Chevron Date of Testing: January 10, 2012 <br />Facility Address: 601 East Kettleman Lane, Lodi, Ca. 95240 <br />Facility Contact: Tony Singh I Phone: (209) 333-0305 <br />Date Local Agency Was Notified of Testing: 12/30/11 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: ❑ 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 <br />Pass <br />Fail <br />Tested <br />Not <br />Repairs <br />Made <br />Component <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />Annular Tank #I <br />X <br />❑ <br />❑ <br />❑ <br />Dispenser Sump #1&2 <br />X <br />❑ <br />❑ <br />0 <br />Annular Tank #2 <br />X <br />❑ <br />❑ <br />❑ <br />Dispenser Sump#3&4 <br />X <br />❑ <br />❑ <br />❑ <br />Annular Tank #3 <br />X I <br />❑ <br />❑ <br />❑ <br />Dispenser Sump#5&6 <br />X <br />0 <br />❑ <br />❑ <br />Annular Tank #4 <br />X <br />❑ <br />❑ <br />❑ <br />Dispenser Sump #7&8 <br />X <br />❑ <br />❑ <br />1 ❑ <br />Secondary Pipe #I <br />X <br />❑ <br />❑ <br />❑ <br />Dispenser Sump #9& 10 <br />X <br />❑ <br />❑ <br />❑ <br />Secondary Pipe #2 <br />X <br />❑ <br />❑ <br />❑ <br />Dispenser Sump #11 & 12 <br />X <br />❑ <br />0 <br />❑ <br />Secondary Pipe #3 <br />X <br />❑ <br />0 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Secondary Pipe #4 <br />X <br />0 <br />0 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Piping Sump #1 <br />X <br />0 <br />0 <br />❑ <br />0 <br />❑ <br />❑ <br />1 ❑ <br />Piping Sump #2 <br />X <br />❑ <br />0 <br />0 <br />❑ <br />❑ <br />0 <br />❑ <br />Piping Sump #3 <br />X <br />0 <br />0 <br />❑ <br />❑ <br />0 <br />❑ <br />❑ <br />Piping Sump #4 <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />0 <br />❑ <br />❑ <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: ��� J9 ffff aatWV_'1f Date: January 10, 2012 <br />