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JU418 2015 <br />SN,VRCB, January 2002Page of <br />-I�ViHONIb1ERliA�. <br />Secondary Containment Testing- portftrm` <br />This form is intended for use by contractors performing periodic testing of UST secondary containment systems. 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 (ifapplicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />I FACII.ITV INFORMATION <br />Facility Name: Lathrop Gas & Food/Chevron Date of Testing: January 29, 2015 <br />Facility Address: 140 Lathrop Road, Lathrop, Ca. 95330 <br />Facility Contact: Jesse I Phone: (209) 982-5005 <br />Date Local Agency Was Notified of Testing: 1/23/2015, by Afford -A -Test <br />Name of Local Agency Inspector (ifpresent during testing): <br />FWk%XM0fffff1VW IK11111MKIOLUN17KAlia <br />Company Name: R&D Compliance Testing <br />Technician Conducting Test: Benjamin F. Duncan Jr. <br />Credentials: ❑ CSLB Licensed Contractor X SWRCB Licensed Tank Tester <br />License Type: Tank Tester <br />License Number: 90-1120/ICC #5246802 -UT <br />Manufacturer Training <br />Manufacturer Component(s)) Date Trainine Ex ires <br />Caldwell Systems Level Chane Indicator July, 2016 <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <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 #I <br />X <br />❑ <br />❑ <br />❑ <br />Dispenser Sump 47&8 <br />X <br />❑ <br />❑ <br />❑ <br />Annular Tank 92 <br />X <br />❑ <br />❑ <br />❑ <br />Dispenser Sump #9&10 <br />X <br />❑ <br />❑ <br />❑ <br />Annular Tank #3 <br />X <br />❑ <br />❑ <br />❑ <br />Dispenser Sump 411&12 <br />X <br />❑ <br />❑ <br />❑ <br />Secondary Pipe #1 <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Secondary Pipe #2 <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Secondary Pipe 43 <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Piping Sump #1 <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />I ❑ <br />Piping Sump #2 <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Piping Sump 43 <br />X <br />L1 <br />El <br />[1 <br />11 <br />11 <br />11Dispenser <br />Sump #1&2 <br />X <br />El <br />❑ <br />❑ <br />❑ <br />❑ <br />I ❑ <br />❑ <br />❑ <br />Dispenser Sump #3&4 <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />1 ❑ <br />❑ <br />❑ <br />Dispenser Sump #5&6 <br />X <br />❑ <br />❑ <br />1 ❑ <br />❑ <br />I ❑ <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 the best of my knowledge, the facttssssstrated in this document are accurate and in full compliance with legal requirements <br />Technician's Signature: January 29.2015 <br />