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"-�age,— of <br />EC <br />' g.- . <br />v!' <br />Sfianuary2002 Testing Report Form the_ <br />Secondary containmentcontainment sys � �'49d <br />o UST secondary written test procedure <br />periodic testing f leted orm, atorryl agency <br />or use by contractors performing onents tested. The comp f A69i1� r`�N COU,ti?y <br />This form is pages oft orm to report results for all compone <br />owner/operator for submittal to th ENVIRONMEn. i„ <br />appropriate pages of thisform should be provided to the f <br />hcable)'pRMATION epfe t7?2011 <br />printouts from tests (if app FACILITY Date of Testing: <br />?aciljtyNarnV <br />Facility Address. <br />Facili <br />Date Local <br />Name <br />Compa�ame: <br />TechnicConi <br />Credentials: <br />License Type_ <br />Em� General store <br />4407 East Waterloo Rd., <br />Erie Giannecc -- <br />Was Notified of T <br />Ca. 95215 <br />Phone: (209) 931-2850 <br />8/25/11 by Afford <br />R&DCompna",--. <br />Ring Test: Benjamin F. Duncan Jr. <br />X SWRCB Licensed Tank Tester <br />❑ CSLB Licensed Contractor I License Number: 90-1120/ICC #5246802 -UT <br />Tank Tester <br />3. <br />SUMMARY <br />OF TEST RESULTS <br />Not <br />Repairs <br />Not <br />Repairs <br />Component <br />Pass <br />Fail <br />Tested <br />Made <br />Component <br />Pass <br />Fail <br />Tested <br />Made <br />Dispenser Sump #9&10 -RT <br />X <br />❑ <br />❑ <br />❑ <br />Tank #1 <br />X <br />❑ <br />❑ <br />❑ <br />Dispenser Sump #1&2 -CL <br />X <br />❑ <br />❑ <br />❑ <br />Tank #2&3 <br />X <br />❑ <br />❑ <br />❑ <br />Dispenser Sump #3&4 -CL <br />X <br />❑ <br />❑ <br />❑ <br />ry Pipe #1 <br />X <br />❑ <br />❑ <br />❑ <br />Dispenser Sump #5&6 -CL <br />X <br />❑ <br />❑ <br />❑ <br />ry Pipe #2 <br />X <br />❑ <br />❑ <br />❑ <br />Dispenser Sump #7&8 -CL <br />X <br />❑ <br />El <br />ry Pipe #3 <br />X <br />❑ <br />❑ <br />❑ <br />Dispenser Sump 9&10 -CL <br />X <br />❑ <br />❑ <br />❑ <br />lump 41 <br />X <br />❑ <br />❑ <br />❑ <br />lump #2 <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />lump #3 <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />er Sump #1&2 -RT <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />ler Sump #3&4 -RT <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />ler Sump #5&6 -RT <br />X <br />❑ <br />A:]] <br />❑ <br />❑...., <br />e.,.,,,, R7R,R-RT <br />X <br />❑ <br />❑ <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />_ , I .,,,,t --11 -- for reuse by, R&D Compliance Testing. <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTLNG'I nra i no <br />To the best of my knowledge, the facts stated in tills document are accurate and in full compliance with legal requirements <br />T'echnician's Signature: +in� <br />Date: September Ol 1 <br />