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NED <br /> 3 U L 173 Z <br /> SWRCB,January 2002 Page_of <br /> EL-NTAL <br /> i IFpn�ZT�fi.ENT <br /> Secondary Containment Testing Report For <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 ownerloperatorfor submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Quick N Easy Mart I Date of Testing: June 25,2018 <br /> Facility Address: 2057 South El Dorado Street,Stockton,Ca.95206 <br /> Facility Contact: Aparana Bali I Phone: (510)304-0260 <br /> Date Local Agency Was Notified of Testing: 5/10/2018 <br /> Name of Local Agency Inspector(ii(present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Afford-a-test <br /> j Conducting ting Te t. <br /> Technician=Conducting Test: Benjamin F.Duncan Jr./ICC#5246802-UT <br /> Credentials: <br /> Credentials: X CSLB Licensed Contractor X SWRCB Licensed Tank Tester <br /> License <br /> -1120 <br /> icense Type: A License Number: CSLB Lic.#341375/SWRCB Lic.#90 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> Caldwell Systems Piping Sumps/TJDCs July 5, 2020 <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#1-91&2-87 x 0 L1 0 El Ll E El <br /> Secondary Pipe #1-91 X El El 0 [1 E [I El <br /> Secondary Pipe #2-87 x 11 0 11 E El 0 El <br /> Piping Sump#1-91 x 0 0 11 El E El El <br /> Piping Sump#2-87 X [I El L1 El [I [I El <br /> Dispenser Sump#1&2 X 0 El 11 El El El El <br /> Dispenser Sump#3&4 x [I El 0 Ll El <br /> Dispenser Sump#5&6 X 11 [1 L1 El L1 <br /> Dispenser Sump#7&8 X El El Ll El L1 [I El <br /> 11 11 Ll 11 11 11 11 11 <br /> [I El 0 11 El El 11 E <br /> Ll El El El El Ll E 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. <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: Date: June 25,2018 <br />