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E IVD RE�E SWRCB, January 2002 g Secondary Containment Testing Report Form OCT 21197- 201fi This form is intended for use by contractors performing periodic testing of UST secondary containment systeg;yffAt HEALTH appropriate pages of this form to report results for all components tested The completed form,] printouts from tests (ifapplicable), should be provided to the facility owner/operator for submitFal to the a agency. 1. FACILITY INFORMATION Facility Name: Ernie's General Store I Date of Testing: 9/12/2017 Facility Address: 4407 East Waterloo Rd., Stockton, Ca. 95215 Facility Contact: Ernie Giannecchini I Phone: (209) 931-2850 Date Local Agency Was Notified of Testing: 8/8/2017 Name of Local Agency Inspector (ifpresent during testing): 2. TESTING CONTRACTOR INFORMATION Company Name: Afford -a -test Pass Technician Conducting Test: Benjamin F. Duncan Jr./ICC #5246802 -UT Credentials: X CSLB Licensed Contractor X SWRCB Licensed Tank Tester License Type: A License Number: CSLB Lie. #341375/SWRCB Lie. #90-1120 Manufacturer Manufacturer Training Component(s) Date Training Ex ires Caldwell Systems Piping Sum s/UDC's July 5, 2020 X ❑ ❑ ❑ Dispenser Sump #9&10 -RT X 3. SUMMARY OF TEST RESULTS Component Pass Fail Not Tested Repairs Made Component Pass Fail Not Tested Repairs Made Annular Tank #1 X ❑ ❑ ❑ Dispenser Sump #9&10 -RT X ❑ ❑ ❑ Annular Tank #2&3 X ❑ ❑ ❑ Dispenser Sump #1&2 -CL X ❑ ❑ ❑ Secondary Pipe #1 X ❑ ❑ ❑ Dispenser Sump #3&4 -CL X ❑ ❑ ❑ Secondary Pipe #2 X ❑ ❑ ❑ Dispenser Sump #5&6 -CL X ❑ ❑ ❑ Secondary Pipe #3 X ❑ ❑ ❑ Dispenser Sump #7&8 -CL X ❑ ❑ ❑ Piping Sump #1 X ❑ ❑ ❑ Dispenser Sump 9&10 -CL X ❑ ❑ ❑ Piping Sump #2 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ Piping Sump #3 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ Dispenser Sump #1&2 -RT X ❑ ❑ ❑ ❑ ❑ ❑ ❑ Dispenser Sump #3&4 -RT X ❑ ❑ ❑ ❑ ❑ ❑ ❑ Dispenser Sump #5&6 -RT X ❑ ❑ ❑ ❑ ❑ ❑ ❑ Dispenser Sump #7&8 -RT X ❑ ❑ ❑ ❑ ❑ ❑ ❑ If hydrostatic testing was performed, describe what was done with the water after completion of tests: Test Fluid Supplied and recovered for reuse. RT=Retail Island/CL=Card Lock Island. CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING To the best of my knowledge, the facts stated in this document are accurate and in full compliance with legal requirements Technician's Signature:xfnnslJreree�rez Date: September 12, 2017