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SWRCB JanuaryREDWYED 2002 Page 1 of <br />OCT 0 4 d10 <br />Secondary Containment Testi tO�ffl AfffAWH <br />This form is intended for use by contractors performing periodic testing ofUS t systems. Use the <br />appropriate pages of this form to report results for all components tested. The comp eted orm, wri %n test procedures, and <br />printouts from tests (f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION _ <br />Facility Name: New West # 1003- Lodi Date of Testing: 9/17/2010 <br />Facility Address: 6437 West Banner Street, Lodi, Ca. 95242 <br />Facility Contact: Rupi I Phone: (209) 814-5576 <br />Date Local Agency Was Notified of Testing: NA Escrow only _ <br />Name of Local Agency Inspector (fpresent during testing): <br />L. l r:a l 11V la l: Vlr l KAtf l Vtc llrr V�ri[3 i aviv <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 Training <br />Manufacturer Component(s) Date Training Expires <br />u►�'�NFIRKMW <br />Component <br />Pass Fail <br />Not Repairs <br />Tested Made <br />Component <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />Annular Tank #1 <br />X ❑ <br />❑ ❑ <br />Dispenser Sump #9&10 <br />X <br />❑ <br />❑ <br />_ <br />Annular Tank #2&3 <br />X ❑ <br />❑ ❑ <br />Dispenser Sump #I 1 & 12 <br />X <br />❑ <br />❑ <br />Ll <br />Secondary Pipe #1 <br />X ❑ <br />❑ ❑ <br />Dispenser Sump #13&14 <br />X <br />D <br />❑ <br />Secondary Pipe #2 <br />X ❑ <br />❑ ❑ <br />Dispenser Sump #15&16 <br />X <br />❑ <br />❑ <br />Secondary Pipe #3 <br />X 0 <br />0 0 <br />1 0 <br />0 <br />Piping Sump #1 <br />X ❑ <br />❑ ❑ <br />❑ <br />0 <br />EJ <br />Piping Sump #2 <br />X ❑ <br />❑ 0 <br />❑ <br />0 <br />❑ <br />Piping Sump 43 <br />X ❑ <br />❑ 0 <br />0 <br />0 <br />❑ <br />71 <br />Dispenser Sump #1&2 <br />X❑ <br />❑ 0 <br />0 <br />0. <br />0 <br />J <br />Dispenser Sump #3&4 <br />X ❑ <br />❑ ❑ <br />❑ <br />❑ <br />11 <br />Dispenser Sump#5&6 <br />X❑ <br />❑ ❑ <br />0 <br />0 <br />0 <br />LJ <br />Dispenser Sump#7&8 <br />X ❑ <br />❑ ❑ <br />0 <br />0 <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 doc meat are accurate and in full compliance with legal requirements <br />Technician's Signature: <br />Date: q — 0 - 2v i o <br />0 <br />