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-13 <br /> SWRCB,January 2002 gage of <br /> Secondary Containment Testing Report Fokin.,` <br /> This form is intended for use by contractors performing periodic testing of UST secondary containmieni systemg. 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 ownerloperatorfor submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Ripon Shell Date of Testing: August 22,2013 <br /> Facility Address: 341 East Main St.,Ripon,Ca.95206 <br /> Facility Contact: Angel Balaji Phone: (209)599-4454 <br /> Date Local Agency Was Notified of Testing: 7/24/2013,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: E 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 Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> Secondary Pipe#1 X 11 11 E 11 <br /> i Secondary Pipe #2 X El El El 0 D El 0 <br /> Piping Sump 41 X El El El 0 El El 0 <br /> Piping Sump#2 X 11 11 0 0 El 0 El <br /> Dispenser Sump 41&2 X 11 11 0 0 El El El <br /> Dispenser Sump#3&4 X El El 0 [1 0 El El <br /> Dispenser Sump# 5&6 X El El 0 Ll El [1 0 <br /> Dispenser Sump#7&8 X El El 0 El 0 D [I <br /> El El D 11 El D D 0 <br /> El 11 El El El El El El <br /> El <br /> 0 fiol E 1] 0 0 0 0 <br /> 0 El 0 [1 Li ❑ <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: gwvm� Date: August 22,2013 <br /> C, — <br />