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0 RECEIVED <br />SWRCB, January 2002 Page of <br />Secondary Containment Testing Report Form APP 10 201; <br />This form is intended for use by contractors performing periodic testing of UST secondary containme HEALTH <br />appropriate pages of this form to report results for all components tested. The completed form, writt <br />printouts from tests (f applicable), should be provided to the facility owner/operator for submittal to the local T <br />1_ FAC"TT.TTV INFORMATION <br />Facility Name: CRM -Pacific Avenue Chevron Date of Testing: March 29, 2017 <br />Facility Address: 6633 Pacific Avenue, Stockton, Ca. 95207 <br />Facility Contact: Josh Hammon I Phone: (916) 587-3225 <br />Date Local Agency Was Notified of Testing: 2/10/2017, 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 Tvve: Tank Tester License Number: 90-1120/ICC #5246802 -UT <br />Manufacturer Training <br />Manufacturer Component(s) Date Training Expires <br />Caldwell Svstems Piping Sumps/UDC's July 30, 2017 <br />3_ SITMMARV OF TEST RF:SITLTS <br />Component <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />Component <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />Annular Tank # 1-91 <br />X <br />❑ <br />❑ <br />❑ <br />Dispenser Sump #9& 10 <br />X <br />❑ <br />❑ <br />❑ <br />Annular Tank 42-87 <br />X <br />❑ <br />❑ <br />❑ <br />Dispenser Sump #11&12 <br />X <br />❑ <br />❑ <br />❑ <br />Annular Tank #3-87 <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Secondary Pipe 41-91 <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Secondary Pipe #2&3-87 <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Piping Sump #1-91 <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Piping Sump #2-87 <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Piping Sump #3-87 <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <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 />❑ <br />Dispenser Sump #7&8 <br />X <br />❑ <br />❑ <br />❑ <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: yus��scsa Date: March 29, 2017 <br />