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SWRCB, January 2002 <br />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 ofthisform to report resultsfor all components tested The completedform, written test procedures, and <br />printoutsfrom tests (ifapplicable), should be provided to the facility owner/operatorfor submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: Pershing Gas I Date of Testing: 11/29/2017 <br />Facility Address: 4445 North Pershing Ave., Stockton, Ca. 95207 <br />Facility Contact: Daljit Singh I Phone: (209) 477-8004 <br />Date Local Agency Was Notified of Testing: 10/9/2017 <br />Name of Local Agency Inspector (ifpresent during testing): t= <br />2. TESTING CONTRACTOR INFORMATION p 9, 9 2018 <br />Company Name: Afford -a -test <br />Fail Not Repairs <br />Tested Made <br />Technician Conducting Test: Benjamin F. Duncan Jr. ACC #5246802 -UT <br />Credentials: X CSLB Licensed Contractor <br />X SWRCB Licensed Tank Tester <br />License Type: A <br />License Number: CSLB Lie. #341375/SW0ie. -1120 <br />Manufacturer <br />Manufacturer Training <br />Component(s) Date Training Expires <br />Caldwell Systems <br />Piping Sum s/UDC's July 5, 2020 <br />❑ ❑ <br />Secondary Pipe #2 X <br />❑ ❑ ❑ <br />❑ <br />0 <br />3. SUMMARY OF TEST RESULTS <br />Component Pass <br />Fail Not Repairs <br />Tested Made <br />Component <br />Pass <br />Fail <br />Not Repairs <br />Tested Made <br />Secondary Pipe #1 X <br />❑ ❑ ❑ <br />❑ <br />❑ <br />❑ ❑ <br />Secondary Pipe #2 X <br />❑ ❑ ❑ <br />❑ <br />0 <br />❑ ❑ <br />Secondary Pipe #3 X <br />❑ ❑ ❑ <br />❑ <br />❑ <br />❑ ❑ <br />Piping Sump #1 X <br />❑ ❑ ❑ <br />❑ <br />0 <br />❑ ❑ <br />Piping Sump #2 X <br />❑ ❑ ❑ <br />❑ <br />0 <br />❑ ❑ <br />Piping Sump #3 X <br />❑ ❑ 0 <br />❑ <br />1 ❑ <br />1 ❑ 1 ❑ <br />Dispenser Sump #1&2 X <br />❑ ❑ ❑ <br />❑ <br />0 <br />❑ ❑ <br />Dispenser Sump #3&4 X <br />❑ ❑ 0 <br />❑ <br />❑ <br />❑ ❑ <br />Dispenser Sump #5&6 X <br />❑ ❑ ❑ <br />❑ <br />❑ <br />❑ ❑ <br />❑ <br />❑ ❑ ❑ <br />❑ <br />❑ <br />❑ 0 <br />❑ <br />❑ ❑ ❑ <br />0 <br />0 <br />❑ 0 <br />❑ <br />❑ 0 ❑ <br />❑ <br />❑ <br />❑ 0 <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. <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: November 29, 2017 <br />