Laserfiche WebLink
1 ' RECEIVED <br /> SWRCB,January 2002 Page, of <br /> APb <br /> Secondary Containment Testing Report Form <br /> This form is intended for use by contractors performing periodic testing of UST secondary containment sy 4 TAS°" <br /> appropriate pages of thisform to report resultsfor all components testedThe com letedform, written6�9T <br /> printouts from tests(f applicable), should be provided to the facility owner/operator for submittal to the 1oca1 regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Country Mart Gas&Food I Date of Testing: March 28,2018 <br /> Facility Address: 34243 South Chrisman Road,Tracy,Ca.95376 <br /> Facility Contact: Taranjit Sandhu I Phone: (209)832-8642 <br /> Date Local Agency Was Notified of Testing: 2/13/2018 <br /> Name of Local Agency Inspector(fpresent during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Afford-a-test <br /> Technician Conducting Test: Benjamin F.Duncan Jr./ICC#5246802-UT <br /> Credentials: X CSLB Licensed Contractor X SWRCB Licensed Tank Tester <br /> License Type: A License Number: CSLB Lic.#341375/SWRCB Lic.#90-1120 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> Caldwell Systems Piping Sum s/UDC's 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 X ❑ ❑ ❑ Dispenser Sump#3&4 X ❑ ❑ ❑ <br /> Annular Tank#2&3 X ❑ ❑ ❑ Dispenser Sump#5&6 X ❑ ❑ ❑ <br /> Annular Tank#4 X ❑ ❑ ❑ Dispenser Sump#7&8 X ❑ ❑ ❑ <br /> Secondary Pipe#1 X I ❑ ❑ I ❑ Dispenser Sump#9&10 X ❑ ❑ ❑ <br /> Secondary Pipe#2 X ❑ ❑ ❑ Dispenser Sump#11&12 X ❑ ❑ ❑ <br /> Secondary Pipe#3 X ❑ ❑ ❑ Dispenser Sump#I IS X ❑ ❑ ❑ <br /> Secondary Pipe#4 X ❑ ❑ ❑ Dispenser Sump#12S&13 X ❑ ❑ ❑ <br /> Piping Sump#1 X ❑ ❑ ❑ Dispenser Sump#13S&14 X ❑ ❑ ❑ <br /> Piping Sump#2 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Piping Sump#3 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Piping Sump#4 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Dispenser Sump#1&2 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <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: � a Date: March 28,2018 <br />