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SWRCB,January 2002 <br /> Secondary Containment Testing Report Form-, <br /> This form is intended for use by contractors performing periodic testing of UST secondary containnient'-systems. <br /> appropriate pages of this form to report results for all components tested The completed form, written test procedures, and <br /> printouts from tests(if applicable), should be provided to the facility ownerloperatorfor submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Super Stop Market I Date of Testing: July 20,2015 <br /> Facility Address: 290 North Main Street,Manteca,Ca.95336 <br /> Facility Contact: Mandeep Dua I Phone: (209)239-4475 <br /> Date Local Agency Was Notified of Testing: 6/10/2015,by Afford-A-Test <br /> Name of Local Agency Inspector(ifpresent 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 Piping Sumps/UDC's July, 2017 <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&2 X ❑ ❑ ❑ Dispenser Sump#9&10 X ❑ ❑ ❑ <br /> Annular Tank#3 X ❑ ❑ ❑ Dispenser Sump#11&12 X ❑ ❑ ❑ <br /> Secondary Pipe#1 x ❑ ❑ 1 ❑ ❑ ❑ ❑ ❑ <br /> Secondary Pipe#2 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Secondary Pipe#3 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Piping Sump#1 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Piping Sump#2 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Piping Sump#3 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Dispenser Sump#1&2 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Dispenser Sump#3&4 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Dispenser Sump#5&6 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Dispenser Sump#7&8 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <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: Date: July 20,2015 <br />