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RECEIVED <br /> ' SWRCB,January 2002 BAR 2 1� Page i of <br /> Secondary Contain ort Form <br /> PER ITIS ES <br /> This form is intended for use by contractors performing periodic testing of UST secondary 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 /> 1. FACILITY INFORMATION <br /> Facility Name: San Joaquin County Jail I Date of Testing: March 1,2011 <br /> Facility Address: 7000 Michael Canlis Blvd.,French Camp,Ca. 95231 <br /> Facility Contact: Tom Valtierra I Phone: (209)468-3105 <br /> Date Local Agency Was Notified of Testing: 2/23/11 by Afford-A-Test <br /> Name of Local Agency Inspector(rf present 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 Trainin; <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 /> Annular Tank#1 X ❑ ❑ ❑ ❑ ❑ ❑ <br /> Annular Tank#2 X ❑ ❑ ❑ ❑ ❑ Li <br /> Secondary Pipe#1 X ❑ ❑ ❑ ❑ ❑ ❑ <br /> Secondary Pipe#2 X ❑ ❑ ❑ ❑ ❑ <br /> Secondary Pipe#3 X ❑ ❑ ❑ ❑ ❑ ❑ <br /> Secondary Pipe#4 X ❑ ❑ ❑ ❑ ❑ ❑ <br /> Piping Sump#1 X ❑ ❑ ❑ ❑ ❑ ❑ <br /> Piping Sump #2 X ❑ ❑ ❑ ❑ ❑ 11 <br /> ❑ ❑ ❑ ❑ ❑ ❑ u <br /> 0 El <br /> ❑ El I ❑ ❑ ❑ ❑ ❑ <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: �u Date: March 1,2011 <br />