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SWRCB, January 2002 Secondary Containment Testing Report Form Page of This form is intended for use by conb actors 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 2. TESTING CONTRACTOR INFORMATION Company Name: Afford -a -test Facility Name: Refuel Circle K I Date of Testing: May 15, 2018 Facility Address: 419 South Main St., Manteca, Ca. 95366 Facility Contact: Al or Simi, Manager Phone: (209) 276-7013 Date Local Agency Was Notified of Testing : 4/10/2018 Name of Local Agency Inspector (if present darr•ing testing): Repairs Made Component 2. TESTING CONTRACTOR INFORMATION 3. SUMMARY OF TEST RESULTS Company Name: Afford -a -test Technician Conducting Test: Benjamin F. Duncan Jr. /ICC #5246802 -UT Credentials: X CSLB Licensed Contractor X SWRCB Licensed Tank Tester License Type: A License Number: CSLB Lie. #341375/S)VRCB Lie. #90-1120 Manufacturer Trainine Manufacturer Component(s) Date Training Expires Caldwell Systems Piping Sum s/UDC's July 5, 2020 Fail Not Tested Repairs Made Component Pass Fail 3. SUMMARY OF TEST RESULTS If hydrostatic testing was performed, describe what was done with the water after completion of tests: Test Fluid Supplied and Recovered for reuse. 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: �Je�2�' .�nr.�iai �o1/ty2ctr�L�i. Date: May 15, 2018 Component Pass Fail Not Tested Repairs Made Component Pass Fail Not Tested Repairs Made Annular Tank #1 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ Annular Tank #2 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ Annular Tank #3 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ Secondary Pipe #1 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ Secondary Pipe #2 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ Secondary Pipe #3 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ Piping Sump #1 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ Piping Sump #2 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ Piping Sump #3 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ Dispenser Sump #1&2 X ❑ ❑ ❑ ❑ FEI ❑ ❑ Dispenser Sump #3&4 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ If hydrostatic testing was performed, describe what was done with the water after completion of tests: Test Fluid Supplied and Recovered for reuse. 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: �Je�2�' .�nr.�iai �o1/ty2ctr�L�i. Date: May 15, 2018