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S WRCB,`January 2002 Page of 21— <br />Secondary <br />_ -Secondary Containment Testing Report F <br />This form is intended for use by contractors performing periodic testing of UST secondary contwi .s ms. se the <br />appropriate pages of this form to report results for all components tested. The completed form, written t ��' e � d <br />printouts from tests (if applicable), should be provided to the facility owner/operator for submittal to th tkl g .la7ory agency. <br />1. FACILITY INFORMATION F14VIRUNMENT <br />Facility Name: Ripon Shell Date of Testing: FUM 1QVAV1VtW0 <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: 7/30/2010 by Afford -A -Test <br />Name of Local Agency Inspector (rf present during testing): <br />h#IY�f.Ylli►�lT�•i►`tl1i • : 1►1 • : ►� :, • U <br />Company Name: R&D Compliance Testing <br />Technician Conducting Test: Benjamin F. Duncan Jr. <br />Credentials: 0 CSLB Licensed Contractor X SWRCB Licensed Tank Tester <br />License Type: Tank Tester <br />License Number: 90-1120/ICC#5246802-UT <br />Manufacturer Training <br />Manufacturer Component(s) Date Training Expires <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />Secondary Pipe #1 <br />Component <br />Pass <br />Fail <br />Not Repairs <br />Tested Made <br />Component <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />Secondary Pipe #1 <br />X <br />❑ <br />❑ ❑ <br />❑ <br />❑ <br />❑ <br />Secondary Pipe #2 <br />X <br />❑ <br />❑ ❑ <br />❑ <br />❑ <br />El <br />Piping Sump #1 <br />X <br />❑ <br />❑ ❑ <br />1 ❑ <br />❑ <br />❑ <br />Piping Sump #2 <br />X <br />❑ <br />❑ ❑ <br />❑ <br />❑ <br />❑ <br />Dispenser Sump 41&2 <br />X <br />❑ <br />❑ ❑ <br />n <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 />❑ <br />❑ <br />Dispenser Sump #7&8 <br />X <br />❑ <br />❑ ❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ ❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ ❑ <br />❑ <br />❑ <br />0 <br />❑ <br />❑ <br />❑ ❑ <br />❑ <br />❑ <br />❑ <br />❑ <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 lite best of my knowledge, the facts stated in this document are accurate and in full compliance with legal requirements <br />j.. r <br />Technicians Signature: ,C - / <br />g ..,a-- t� Date: r <br />