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RECEIVED <br /> SWRCB,January 2002 e of <br /> Secondary Containment Testing Report Form 2015 <br /> This form is intended for use by contractors performing periodic testing of UST secondary containment syst, . _ , <br /> appropriate pages of this form to report results for all components tested. The completed form, written test procedures, rl- <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 28,2015 <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: 1/23/2015,by Afford-A-Test <br /> Name of Local Agency Inspector(i(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 /> Caldwell Systems Level Change Indicator July, 2016 <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 ❑ ❑ ❑ Dispenser Sump#1&2 X ❑ ❑ 0 <br /> Annular Tank#2 X ❑ ❑ ❑ Dispenser Sump#3&4 X ❑ ❑ ❑ <br /> Annular Tank#3 X ❑ ❑ ❑ Dispenser Sump#5&6 X ❑ ❑ ❑ <br /> Annular Tank#4 X ❑ ❑ ❑ Dispenser Sump#7&8 X ❑ ❑ ❑ <br /> Secondary Pipe#I X ❑ ❑ ❑ Dispenser Sump#9&10 X ❑ ❑ ❑ <br /> Secondary Pipe#2 X ❑ ❑ ❑ Dispenser Sump#11&12 X ❑ ❑ ❑ <br /> Secondary Pipe#3 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Secondary Pipe#4 X ❑ ❑ ❑ ❑ 0 ❑ ❑ <br /> Piping Sump#1 X 0 ❑ ❑ 0 ❑ 0 0 <br /> Piping Sump#2 X ❑ ❑ ❑ 0 0 ❑ 0 <br /> Piping Sump#3 X ❑ ❑ ❑ 0 0 0 0 <br /> Piping Sump#4 X ❑ I ❑ ❑ 0 0 0 0 <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: nth Date: January28,2015 <br />