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rno E (�� E � V E 10 --sw <br />SWRCB, January 2002 s it r 1 4 2010 Page i of <br />Secondary Containment TestingfN4 iffi4 ALTH <br />This form is intended for use by contractors performing periodic testing of UST JUMIUE 04cKstems. 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: Valley Service Station Date of Testing: August 24, 2010 <br />_ <br />Facility Address: I6 East Harding Way, Stockton, Ca. 95204 <br />Facility Contact: Abraham Cyrus <br />I Phone: (209) 466-9516 <br />Date Local Agency Was Notified of Testing: 8/5/2010 <br />_ <br />Name of Local Agency Inspector (fpresent during testing): <br />Pass <br />2. TESTING CONTRACTOR INFORMATION _ <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: 90-1 120/ICC#5246802-IJT <br />Manufacturer Training <br />Manufacturer Component(s) Date Training Expires <br />3. SUMMARY OF TEST RESULTS <br />Component <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />Component <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />Annular Tank #1 <br />X <br />❑ <br />❑ <br />❑ <br />Dispenser Sump #9& 10 <br />X <br />❑ <br />❑ <br />❑ _ <br />Annular Tank #2&3 <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Secondary Pipe #1 <br />X <br />1 ❑ <br />❑ <br />1 ❑ <br />_ <br />❑ <br />❑ <br />❑ <br />Secondary Pipe #2 <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />_ <br />❑ <br />❑ _ <br />Secondary Pipe #3 <br />X <br />❑ <br />❑ <br />❑ <br />___ <br />❑ <br />❑ <br />❑ <br />Piping Sump #1 <br />X <br />❑ <br />❑ <br />❑ <br />_ <br />❑ <br />❑ <br />❑ <br />Piping Sump #2 <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Piping Sump 43 <br />X <br />❑ <br />❑ <br />❑ <br />--- — <br />❑ <br />❑ <br />❑ <br />Dispenser Sump #1&2 <br />X <br />❑ <br />❑ <br />❑ <br />_ <br />❑ <br />❑ <br />❑ <br />Dispenser Sump #3&4 <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Dispenser Sump#5&6 <br />X <br />❑ <br />❑ <br />❑ <br />_ _ <br />0 <br />❑ <br />0 <br />Dispenser Sump #7&8 <br />X <br />❑ <br />❑ <br />❑ <br />_ <br />❑ <br />❑ <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 lite best of my knowledge, the facts stated in this document are accurate and in full compliance with legal requirements <br />- �Technician's Stgnature:< ,1' �> .�-- w Date: <br />Ss c. E-44 <br />