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GP <br />SWRCB,�anuary 2002 age,, of _ <br />b � I <br />Secondary Containment Testing Report Form <br />This form is intended for use by contractors performing periodic testing of UST secondary containment systW IJV the., <br />appropriate pages of this form to report results for all components tested. The completed form, written test procedure ,'Ad <br />printouts from tests (if applicable), should be provided to the facility owner/operator for submittal to th%4Aq9�,fflf aato.21 gY cy. <br />JIV <br />I FAd"Tr TTV YNWnRMATION ENVIRONNI[n.T;, <br />Facility Name: Ernie's General Storey- Date of Testing: epte ?2011 <br />Facility Address: 4407 East Waterloo Rd., Stockton, Ca. 95215 <br />Facility Contact: Ernie Giannecchini I Phone: (209) 931-2850 <br />Date Local Agency Was Notified of Testing: 8/25/11 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 License Number: 90-1120ACC #5246802 -UT <br />Manufacturer Training <br />Manufacturer Component(s) Date Training Expires <br />1 cr1N4MARV OF TEST RESULTS <br />Component <br />V _Not <br />Pass <br />Fail <br />Tested <br />Repairs <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 #9&10 -RT <br />X <br />❑ <br />❑ <br />❑ <br />Annular Tank #2&3 <br />X <br />❑ <br />❑ <br />❑ <br />Dispenser Sump #1&2 -CL <br />X <br />❑ <br />❑ <br />❑ <br />Secondary Pipe #1 <br />X <br />❑ <br />❑ <br />❑ <br />Dispenser Sump #3&4 -CL <br />X <br />❑ <br />❑ <br />❑ <br />Secondary Pipe #2 <br />X <br />❑ <br />❑ <br />❑ <br />Dispenser Sump #5&6 -CL <br />X <br />❑ <br />❑ <br />❑ <br />Secondary Pipe #3 <br />X <br />❑ <br />❑ <br />❑ <br />Dispenser Sump #7&8 -CL <br />X <br />❑ <br />❑ <br />❑ <br />Piping Sump #1 <br />X <br />❑ <br />❑ <br />❑ <br />Dispenser Sump 9&10 -CL <br />X <br />❑ <br />❑ <br />❑ <br />Piping Sump #2 <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Piping Sump #3 <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Dispenser Sump #1&2 -RT <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Dispenser Sump #3&4 -RT <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Dispenser Sump #5&6 -RT <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Dispenser Sump #7&8 -RT <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />1 ❑ <br />1 ❑ <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 />RT=Retail Island/CL=Card Lock Island. <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 />_1/resaaasr <br />Technician's Signature: �N+fs*�Date: September 7, 2011 <br />z <br />