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RECEN4 <br />SWRCB, January 2002 ; 2010 <br />Page of <br />Secondary Containme Form <br />This form is intended for use by contractors performing periodic tWN s 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 (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />FAfUTTV INFORMATION <br />Facility Name: Statewide Petroleum 76 Date of Testing: 9/29/2010 <br />Facility Address: 1700 East Yosemite Ave, Manteca, Ca. 95336 <br />Facility Contact: Sunny Bhullar Phone: (209) 823-7676 <br />Date Local Agency Was Notified of Testing: 9/28/10 by Afford-A-Test/Ok per SJ EHS <br />Name of Local Agency Inspector (fpresent during testing): <br />— i1311.111 lizCl'I[KI7 I II: , �K r��:a � i atu.�►�t r_� c��► <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: 90-11201ICC #5246802 -UT <br />Manufacturer <br />Manufacturer Training <br />Component(s) <br />1 fiITMMARV nF TEST RFSITI,TS <br />Date <br />Component <br />Pass Fail <br />Not <br />Tested <br />Repairs Component <br />Made <br />Pass <br />Fail Not <br />Tested <br />Repairs <br />Made <br />Annular Tank #1 <br />X ❑ <br />❑ <br />❑ <br />❑ ❑ <br />❑ <br />Annular Tank #2 <br />X ❑ <br />❑ <br />❑ <br />❑ ❑ <br />❑ <br />Secondary Pipe #1 <br />X ❑ <br />❑ <br />❑ <br />❑ ❑ <br />❑ <br />Secondary Pipe #2 <br />X ❑ <br />❑ <br />❑ 11 <br />❑ ❑ <br />❑ <br />Piping Sump #1 <br />X ❑ <br />❑ <br />❑ <br />❑ ❑ <br />❑ <br />Piping Sump #2 <br />X ❑ <br />❑ <br />❑ <br />❑ ❑ <br />❑ <br />Dispenser Sump #1&2 <br />X ❑ <br />❑ <br />❑ <br />❑ ❑ <br />❑ <br />Dispenser Sump #3&4 <br />X ❑ <br />❑ <br />❑ <br />❑ <br />❑ ❑ <br />❑ <br />Dispenser Sump #5&6 <br />X ❑ <br />❑ <br />❑ <br />❑ <br />u ❑ <br />❑ <br />Dispenser Sump #7&8 <br />X ❑ <br />❑ <br />❑ <br />❑ <br />❑ ❑ <br />❑ <br />❑ <br />❑ <br />11❑ <br />El❑ <br />]]LE]l <br />❑ <br />11❑ <br />Ll❑ <br />El <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: WDate: 9/30/2010 <br />Page 1 of 7 <br />