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SWRCB, January 2002 11 Secondary Containment Testing Report Form Page of This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the appropriate pages of this form 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. 1. FACILITY INFORMATION Facility Name: Countryside Liquor & Gas Date of Testing: March 16, 2016 Facility Address: 14971 North Hwy 88, Lodi, Ca. 95240 Facility Contact: Bill or Rupi I Phone: (209) 368-5380 Date Local Agency Was Notified of Testing: 2/19/2016, by Afford -A -Test Name of Local Agency Inspector (f present during testing): 2. TESTING CONTRACTOR INFORMATION 3. SUMMARY OF TEST RESULTS Component Pass Fail Not Repairs Component Pass Fail Not Repairs Secondary Pipe #3 -Diesel X ❑ Tested Made ❑ ❑ Tested Made Annular Tank #1,2&3 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ Secondary Pipe #1-87 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ Secondary Pipe #2-91 X ❑ ❑ 1 ❑ ❑ ❑ ❑ ❑ Secondary Pipe #3 -Diesel X ❑ ❑ ❑ ❑ ❑ ❑ ❑ Piping Sump #1-87 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ Piping Sump #2-91 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ Piping Sump #3 -Diesel X ❑ ❑ ❑ ❑ ❑ ❑ ❑ Dispenser Sump #1&2 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ Dispenser Sump #3&4 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ El 11 ElEl❑ ❑ El El If hydrostatic testing was performed, describe what was done with the water after completion of tests: Test Fluid Supplied and recovered for reuse by, R&D Compliance Testing. CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING To the best of my knowledge, the facts stated in this document are accurate and in full compliance with legal requirements Technician's Signature:�Date: March 16, 2016„ 1