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SWRCB',January 2002 . . <br /> Page_of <br /> Secondary Containment Testing Report Form R <br /> 7his form is intended for use by contractors performing periodic testing of UST secondary containment sys(e11 IP D <br /> appropriate pages of this form to report results for all components tested. The completed form, writter{Jtest e q�q res, and E <br /> printouts from tests(if applicable), should be provided to the facility owner/operator for submittal to the local ff> � ycy. <br /> 1. FACILITY INFORMATION <br /> Facility Name: SRH Food&Gas Date of Testing <br /> PER <br /> Facility Address: 749 East Charter Way, Stockton, Ca. 95206 g <br /> Facility Contact: Muhammad Rizwan Phone: (209)465-8979 <br /> Date Local Agency Was Notified of Testing : 3/16/11 Ok Per Local CU PA <br /> Name of Local Agency Inspector(tfpresen(during testing): Stacy Rivera, REHS <br /> 2. TESTING CONTRACTOR INFORMATION <br /> 7Ct-edentials: <br /> R&D Compliance Testing <br /> ng Test: Benjamin F. Duncan Jr. ---CSLB Licensed Contractor X SWRCB Licensed Tank Tester <br /> Tank Tester License Number: 90-1 t20/ICC#5246802-UT <br /> Manufacturer Tramine <br /> - Manufacturer Component(s) Date Training Expires <br /> r - -- <br /> 3. SUMMARY OF TEST RESULTS <br /> Component j Pass Fail Not Repairs Not Repairs <br /> Tested Made Component Pass Fail <br /> Tested Made <br /> Annular Tank #2 Reg. 87 X ❑ ❑ ❑ — ❑ ❑ _,— <br /> Annular Tank #3 Super 91 X ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ — ❑ ❑ _-- <br /> ❑ ❑ ❑ ❑ ❑ =i <br /> ❑ ❑ ❑ ❑ ❑ Ell <br /> ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ _ ❑ ❑ ❑ c <br /> ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br /> Annular Test after Construction over Tank Top of Tanks #2 Regular 87 and #3 Super 91. <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge, the facts stater/in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: zDate: March 17 2011 <br /> � 1 7i- <br />