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SWRCB,January 2002 Page of <br /> Secondary Containment Testing Report Form <br /> This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the <br /> appropriate pages of this farm to report results far all components tested. The completed form, written test procedures, and <br /> printouts from tests(tf applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: George's Mini Mart Date of Testing: Apri 126, 2012 <br /> Facility Address: 18662 Hwy. 88,Lockeford,Ca.95237 <br /> Facility Contact: Bill or Rupi Padla Phone: (209)727-3064 <br /> Date Local Agency Was Notified of Testing : 4/23/2012 by Afford-A-Test <br /> Name of Local Agency inspector(if present during testing: <br /> 'I <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: R&D Compliance Testing <br /> Technician Conducting Test: Benjamin F.Duncan Jr. <br /> Credentiais: CSLB Licensed Contractor X SWRCB Licensed Tank Tester <br /> License Type: Tank Tester License Number: 90-1120/ICC#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 /> Annular Tank#I X ❑ ❑ ❑ Dispenser Sump#3&4 X ❑ ❑ ❑ <br /> Annular Tank#2&3 X ❑ ❑ ❑ Dispenser Sump#5&6 X ❑ ❑ ❑ <br /> Annular Tank#4 X ❑ ❑ ❑ Dispenser Sump#7&8 X ❑ ❑ L <br /> Secondary Pipe #1 X ❑ ❑ Dispenser Sump#9&10 X ❑ ❑ ❑ <br /> Secondary Pipe #2 X ❑ ❑ ❑ Dispenser Sump #9s X ❑ ❑ ❑ <br /> Secondary Pipe #3 X ❑ ❑ ❑ Dispenser Sump#I Os X ❑ ❑ ❑ <br /> Secondary Pipe #4 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Piping Sump 41 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Piping Sump#2 X © ❑ ❑ ❑ ❑ ❑ ❑ <br /> Piping Sump#3 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Piping Sump #4 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Dispenser Sump#1&2 X ❑ ❑ ❑ L1 ❑ ❑ 11 <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 the best of my knowledge,the facts stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: Date: April 26 2012 <br />