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' r <br /> SWRCB,January 2002 Page i of <br /> Secondary Containment Testing Report Form <br /> This f arm is intended for use by contractors perjbrming periodic testing of UST secondary containment systems. Use the <br /> appropriate pages of this form to report results for all components tested The completedform, written test procedures, and <br /> printouts from tests(ij'applicable), should be provided to the facility ownerfoperator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Narne: Jimco Truck Plaza I Date of Testi jnj4&ust 26,2010 <br /> Facility Address: 1022 Frontage Rd.,Ripon,Ca. 95206 9:1 Vpn <br /> Facility Contact: Greg Kaiser Phone: (209)599-2112 NA <br /> Date Local Agency Was Notified of Testing: 8/10/2010 by Afford-A-Test ZQ� <br /> Name of Local Agency Inspector(if present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION PERE 17/SEFiViC GAJ rH <br /> Company Name: R&D Compliance Testing <br /> Technician Conducting Test: Benjamin F. Duncan Jr. <br /> Credentials: 0 CSLB Licensed Contractor X SWRCB Licensed Tank Tester <br /> License Type: Tank Tester License Number: 90-1120/[CC#5246802-UT <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> Secondary Pipe 41 X ❑ ❑ ❑ ❑ ❑ ❑ <br /> Secondary Pipe#2 ❑ X ❑ ❑ ❑ ❑ ❑ ❑ <br /> Transition Piping Sump X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ 11 <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ n ❑ ❑ © ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ F1 <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 Ilse best of my knowledge,the facts stated in this document are accurate and in full compliance with legal requirements <br /> C' <br /> Technician's Signature; � � ��/ Date: P -2-Ci "`7_C1� C3 <br /> �C <br />