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SWRCB , January 2002 Page of <br /> Secondary Containment Testing Report Form <br /> This form is intended for use by contractors peformingperiodic 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 (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1 . FACILITY INFORMATION <br /> Facility Name : Alpha Fast Gas Date of Testing : March 29, 2018 <br /> Facility Address : 2358 East Waterloo Road, Stockton, Ca . 95205 <br /> Facility Contact : Kyle Phone : (209) 462-7502 <br /> Date Local Agency Was Notified of Testing : 3/20/2018 <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 Lie . #341375/SWRCB Lie . #90A 120 <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 #7 & 8 X ❑ ❑ ❑ <br /> Annular Tank #2 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Annular Tank #3 X ❑ ❑ 1 ❑ ❑ 1 ❑ ❑ ❑ <br /> Secondary Pipe # 1 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Secondary Pipe #2 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Secondary Pipe #3 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Piping Sump # 1 X ❑ ❑ ❑ ❑ ❑ ❑ 1 ❑ <br /> Piping Sump #2 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Piping Sump #3 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Dispenser Sump # 1 &2 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Dispenser Sump #3 &4 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Dispenser Sump #5 &6 X ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed, describe what was done with the water after rs hof is <br /> Test Fluid Supplied and recovered for reuse . <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR C09-01V 61WWWATIV ` � � 1 <br /> To the best of my knowledge, the facts stated in this document are accurate and in full conpCi ji4P&*TjAWfQd l equirements <br /> Technician ' s Signature : g �=T4 a :r 6 Date : March 29. 2018 <br />