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• RECEIVE[) <br />SWRCB, January 2002 " FEBP290-m f— <br />Secondary Containment Testing Report For'ENVIRJ <br />This form is intended for use by contractors performing periodic testing of UST secondary containmenthl alma ,NTAL. <br />appropriate pages of this form to report results for all components tested The completed form, written test procedures, and aR <br />printouts from tests (f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1. FACILITY INFnPmATrnN <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 (fpresent during testing): <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 Trainin P—;—s <br />Caldwell Systems Level Chane Indicator July, 2016 <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />3. SUMMARY OF TEST RESiTI.TS <br />Component <br />p <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 #7&8 <br />X <br />❑ <br />❑ <br />❑ <br />Annular Tank #2 <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />El— <br />Annular <br />Annular Tank #3 <br />X <br />❑ <br />❑ <br />❑ <br />❑ <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 #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 />❑ <br />❑ <br />❑ <br />Ll <br />❑ <br />Piping Sump #3 <br />*XO <br />El❑ <br />❑ <br />El <br />El❑ <br />Dispenser Sump #1&2 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Dispenser Sump #3&4 <br />X <br />❑ <br />El <br />❑ <br />❑ <br />❑ <br />❑ <br />Dispenser Sump #5&6 <br />X <br />❑ <br />El❑ <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 facts stated in this document are accurate and in full compliance with legal requirements <br />Technician's Signature: ..�fibrs ad�a� '97ff SVaV Jf Date: January 29, 2015 <br />