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RECEIVED <br /> SWRCB,January 2002 FEB 2POPTM-5-of <br /> Secondary Containment Testing Report Fo <br /> TAL <br /> This form is intended for use by contractors performing periodic testing of UST secondary ,containme X.stuwsn, ® qrr <br /> appropriate pages of this form to report results for all components tested. The completed form, written test procedures, and <br /> printouts from tests(f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Knife River Construction Date of Testing: January 27,2015 <br /> Facility Address: 655 West Clay Street,Stockton,Ca.95206 <br /> Facility Contact: Steve Azevdo I Phone: (209)948-0302 <br /> Date Local Agency Was Notified of Testing: 1/23/2015,by Afford-A-Test <br /> Name of Local Agency Inspector(f 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 Training <br /> Manufacturer Component(s) Date Training Expires <br /> Caldwell Systems Level Chane Indicator July, 2016 <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 ❑ ❑ ❑ 0 0 0 0 <br /> Annular Tank#2 X ❑ ❑ ❑ 0 ❑ ❑ 0 <br /> Secondary Pipe #1 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Secondary Pipe#2 X ❑ ❑ ❑ ❑ ❑ ❑ C� <br /> Secondary Pipe #3 X ❑ ❑ ❑ 0 0 ❑ ❑ <br /> Piping Sump#1 X 0 ❑ ❑ 0 0 0 ❑ <br /> Piping Sump#2 X ❑ ❑ ❑ 0 0 0 0 <br /> Dispenser Sump #1&2 X ❑ ❑ ❑ 0 0 0 0 <br /> Dispenser Sump#3&4 X ❑ ❑ ❑ 0 0 0 0 <br /> 0 0 0 0 0 0 0 0 <br /> 0 0 0 0 0 0 0 0 <br /> 0 0 0 0 0 0 0 ❑ <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: ffmymwLsaDate: January 27,2015 <br />