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RECEIVED <br />SWRCB, January 2002 Page of <br />Secondary Containment Testing Report Form AUG 1 <br />This form is intended for use by contractors performing periodic testing of UST secondary cont A HEALTH <br />appropriate pages of this form to report results for all components tested. The completed form, i t t <br />printouts from tests (f applicable), should be provided to the facility owner/operator for submittal to the alrPincy. <br />1. FACILITY INFORMATION <br />Facility Name: Parkwood Gas and Food I Date of Testing: August 14, 2014 <br />Facility Address: 1612 West Hammer Lane, Stockton, Ca. 95213 <br />Facility Contact: Kulwant I Phone: (209) 931-3549 (209) 482-2580 <br />Date Local Agency Was Notified of Testing: 8/5/2014, 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 Trainine <br />Manufacturer Component(s) Date Training Expires <br />3. SUMMARY OF TEST RESULTS <br />Component <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />Component Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />Annular Tank # 1 &3 <br />X <br />❑ <br />❑ <br />❑ <br />0 <br />0 <br />❑ <br />0 <br />Annular Tank #2 <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Secondary Pipe #1 <br />X <br />1 ❑ <br />❑ <br />1 ❑ <br />❑ <br />❑ <br />1 ❑ 1 <br />❑ <br />Secondary Pipe #2 <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Secondary Pipe #3 <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Piping Sump #1 <br />X <br />❑ <br />❑ <br />0 <br />❑ <br />❑ <br />❑ <br />❑ <br />Piping Sump #2 <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Piping Sump #3 <br />X <br />I ❑ <br />❑ <br />I ❑ <br />❑ <br />❑ <br />❑ 1 <br />❑ <br />Dispenser Sump #1&2 <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Dispenser Sump #3&4 <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Dispenser Sump #5&6 <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />0 <br />Dispenser Sump #7&8 <br />X <br />❑ <br />❑ <br />0 <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 the best of my knowledge, the facts stated in this document are accurate and in full compliance with legal requirements <br />Technician's Signature: salsaelJ Date: August 14, 2014 <br />