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SWRCB, January 2002 Page of Secondary Containment Testing Report Form This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the appropriate pages of thisform to report results for all components tested. The completed form, written test procedures, and printouts from tests (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. INFORMATION1. FACILITY Facility Name: El Dorado Food Mart Date of Testing: Pass Fall Not Tested RepairsNot Made Component Facility Address: 2320 N El Dorado St., Stockton, Ca. 95204 Tested Repairs Made Annular Tank #1 - Facility Contact: Bob Luta Phone: (209) 943-1311 Date Local Agency Was Notified of Testing: 8/27/10 ' Name of Local Agency Inspector (f present during testingd: NVIRUNMENT IjEALTH I l Component Pass Fall Not Tested RepairsNot Made Component Tested Repairs Made Annular Tank #1 - ❑ X ❑ Dispenser Sump #7&8 qPassFait ❑ ❑ ❑ Annular Tank #2 1 1❑ X ❑ ❑ ❑ ❑ Annular Tank #3 ❑ X ❑ ❑ ❑ ❑ Secondary Pipe #1 X ❑ ❑ ❑ ❑ ❑ ❑ Secondary Pipe #2 X ❑ ❑ ❑ ❑ ❑ Secondary Pipe #3 X ❑ ❑ ❑ ❑ ❑ ❑ Piping Sump #1 X to ❑ 1 ❑ ❑ ❑ ❑ Piping Sump #2 Piping Sump #3 X X ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ Dispenser Sump # 1 &2 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ Dispenser Sump#3&4 X I ❑ ❑ ❑ ❑ ❑ ❑ ❑ Dispenser Sump#5&6 l.X ❑ ❑ 0 El ❑ ❑ if, t .,`irnetntin tPQtm a waQ nerformed. describe what was done with the water after completion of tests: Test Fluid Sup lied and recovered for reuse by, R&O Compliance t estmg. Annular Tanks are exempt from periodic TestingSee Page #2 ot uns Keport. CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING To the best of my knowledge, the facts stated In tL T and In full compliance with legal requirements Technician's Signature: �^ � Date: