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0,7 <br />SWRCB, January 2002 <br />J et L24tiL <br />Secondary Containment Testing Report Form <br />V� 1 'TL. HEALTH <br />This form is intended for use by contractors performing periodic testing of UST secondary comainmen sys em . e <br />appropriate pages of this form to report results for all components tested. The completed form, written test pr_ se s, a <br />WENT <br />printouts from tests (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: El Dorado Gas & Mart I Date of Testing: February 22, 2017 <br />Facility Address: 1605 South El Dorado St., Stockton, Ca. 95206 <br />Facility Contact: Aziz Phone: (209) 939-1906 <br />Date Local Agency Was Notified of Testing: 1/16/2017, by Afford -A -Test <br />Name of Local Agency Inspector (if 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: E CSLB Licensed Contractor X SWRCB Licensed Tank Tester <br />License Type: Tank Tester License Number: 90-1120/ICC#5246802-UT <br />Manufacturer Training <br />Manufacturer Component(s) Date Training Expires <br />Caldwell Systems Piping Sum s/UDC's July 30, 2017 <br />.• 1 • <br />Component Pass <br />Fail Not <br />Tested <br />Repairs Component Pass <br />Made <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />Annular Tank # 1 &2 X <br />❑ ❑ <br />❑ ❑ <br />❑ <br />❑ <br />❑ <br />Secondary Pipe #1 X <br />❑ ❑ <br />❑ ❑ <br />❑ <br />❑ <br />❑ <br />Secondary Pipe #2 X <br />❑ ❑ <br />❑ ❑ <br />❑ <br />❑ <br />❑ <br />Piping Sump #1 X <br />❑ ❑ <br />❑ ❑ <br />❑ <br />❑ <br />❑ <br />Piping Sump #2 X <br />❑ ❑ <br />❑ ❑ <br />❑ <br />❑ <br />❑ <br />Dispenser Sump #1&2 X <br />❑ ❑ <br />❑ ❑ <br />❑ <br />❑ <br />❑ <br />Dispenser Sump #3&4 X <br />❑ ❑ <br />❑ ❑ <br />❑ <br />❑ <br />❑ <br />Dispenser Sump #5&6 X <br />❑ ❑ <br />❑ ❑ <br />❑ <br />1 ❑ <br />❑ <br />❑ <br />❑ ❑ <br />❑ ❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ ❑ <br />❑ ❑ <br />❑ <br />❑ <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: �Db' na �` �t�aau�a Date: Februga 22, 2017 <br />