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CA SWRCB, January 2002 page of a. Secondary Containment Testing Report Form OCT 2 0 2010 This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the appropriate pages of this form to report results for all components tested. The completed form, written g� edt+esi¢ printouts from tests (if applicable), should be provided to the facility owner/operator for submittal to the lkQq"� ,gzrtdtor " e ency. Facility Name: Ripon Shell I Date of Testing: August 23, 2010 Facility Address: 341 East Main St., Ripon, Ca. 95206 Facility Contact: Angel Balaji Phone: (209) 599-4454 Date Local Agency Was Notified of Testing: 7/30/2010 by Afford -A -Test Name of Local Agency Inspector (if present during testing): 2. TESTING CONTRACTOR INFORMATION Company Name: R&D Compliance Testing Technician Conducting Test: Benjamin F. Duncan Jr. Credentials: ❑ CSLB Licensed Contractor X SWRCB Licensed Tank Tester License Type: Tank Tester License Number: 90-1120/ICC#5246802-UT Manufacturer Training Manufacturer \/ 10. 4"WK11 Date Traini Component Pass Fail Not Tested Repairs Made Component Pass Fail Not Tested Repairs Made Secondary Pipe #1 X ❑ ❑ ❑ ❑ ❑ ❑ Secondary Pipe #2 X ❑ ❑ ❑ ❑ ❑ ❑ Piping Sump #1 X ❑ ❑ ❑ ❑ ❑ ❑ Piping Sump #2 X ❑ ❑ ❑ ❑ ❑ ❑ Dispenser Sump #1&2 X ❑ ❑ ❑ ❑ ❑ ❑ Dispenser Sump #3&4 X ❑ ❑ ❑ ❑ ❑ ❑ Dispenser Sump # 5&6 X ❑ ❑ ❑ ❑ ❑ ❑ Dispenser Sump #7&8 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ If hydrostatic testing was performed, describe what was done with the water after completion of tests: Test Fluid Supplied and recovered for reuse by, R&D Compliance Testing. CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING To the best of my knowledge, the facts stated in this document are accurate and in full compliance with legal requirements Technician's Signature: ■ Date: August 23, 2010