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SWRCB,January 2002 P of <br /> Secondary Containment Testing eort For SPP 1 <br /> This form is intended for use by contractors performing periodic testing of UST secondary cont ' Use the <br /> appropriate pages of this form to report results for all components tested. The completed form, wr ` d <br /> printouts from tests(if applicable),should be provided to thefacility owner/operator for submittal to the Iota re ry agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Kwik Sery Date of Testing: August 30,2011 <br /> Facility Address: 950 West 116 Street,Tracy,Ca.95376 <br /> Facility Contact: Patel I Phone: (209)832-1810 <br /> Date Local Agency Was Notified of Testing: 8/26/11 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: ❑CSLB Licensed Contractor X SWRCB Licensed Tank Tester <br /> License Type: Tank Tester License Number:90-i 120/ICC#5246802-UT <br /> Manufacturer TraininiE <br /> Manufacturer Component(s) Date Training Expires <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail TNNott RMades <br /> Tested Made <br /> Annular Tank#1 X ❑ ❑ ❑ Dispenser sump#7&8 X ❑ ❑ 0 <br /> Annular Tank#2 X 0 0 ❑ 0 0 0 <br /> Annular Tank#3 x ❑ 1 ❑ ❑ 01 ❑ ❑ <br /> Secondary Pipe#1 X ❑ ❑ ❑ 0 ❑ ❑ <br /> Secondary Pipe#2 x ❑ ❑ 0 0 0 ❑ <br /> Secondary Pipe#3 X ❑ ❑ ❑ 0 0 ❑ <br /> Piping Sump#1 X ❑ ❑ ❑ ❑ 0 ❑ <br /> Piping Sump#2 X ❑ ❑ ❑ ❑ 0 0 ❑ <br /> Piping Sump#3 X ❑ ❑ 0 ❑ ❑ ❑ ❑ <br /> Dispenser Sump#1&2 x ❑ ❑ ❑ 0 ❑ 0 <br /> Dispenser Sump#3&4 X ❑ ❑ 0 ❑ 0 ❑ ❑ <br /> Dispenser Sump#5&6 X 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 /> See comments pale#2 of this report,for Tank#1 Diesel Annular! <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: Date: August 30.2011 <br />