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SWRCB , January 2002 Page of <br /> Secondary Containment Testing Report Form <br /> This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the <br /> appropriate pages of this form to report results for all components tested. The completed form, written 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 : Super Stop Market Date of Testing : July 23 , 2018 <br /> Facility Address : 290 North Main Street, Manteca, Ca. 95336 <br /> Facility Contact : Mandeep Dua Phone : (209) 2394475 <br /> Date Local Agency Was Notified of Testing : 7/ 19/2018 <br /> Name of Local Agency Inspector (f present dining testing) : <br /> 2 . TESTING CONTRACTOR INFORMATION j1 <br /> Company Name : Afford-a-test <br /> Al <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 Lie . #341375/SWR6 ' 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 /> I SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> Annular Tank # 1 &2 X ❑ ❑ ❑ Dispenser Sump #9 & 10 X ❑ ❑ ❑ <br /> Annular Tank #3 X ❑ ❑ ❑ Dispenser Sump # 11 & 12 X ❑ ❑ ❑ <br /> Secondary Pipe # 1 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Secondary Pipe #2 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Secondary Pipe 43 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Piping Sump # 1 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Piping Sump #2 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Piping Sump 93 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Dispenser Sump # 1 &2 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Dispenser Sump #3 &4 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Dispenser Sump #5 & 6 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Dispenser Sump #7& 8 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 nzy knowledge, the facts stated in this document are accurate and in full compliance with legal requirements <br /> Technician ' s Signature : �W izlr� e 0 � 5A Date : July 23 , 2018 <br />