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• RECEIVED <br /> SWRCB,January 2002 mRf rnoi5— <br /> Secondary Containment Testing Report AL <br /> Forn�� <br /> This form is intended for use by contractors performing periodic testing of UST secondary contaimAr N��IIeENTT <br /> appropriate pages of this form to report results for all components tested The completed form, written test procedures, dV <br /> clOT <br /> printouts from tests(ifopplicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Save on Gas Date of Testing: February 25,2015 <br /> Facility Address: 420 West Yosemite Ave.,Manteca,Ca.95336 <br /> Facility Contact: Pal Phone: (209)239-4700 <br /> Date Local Agency Was Notified of Testing: 1/26/2015,by Afford-A-Test <br /> Name of Local Agency Inspector(fpresent during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <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:90-1120/ICC#5246802-UT <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Ex fres <br /> Caldwell Systems Piping Sum s/UDC's July, 2016 <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Not Repairs <br /> Component EX <br /> Fail Tested RMades Component Pass Fail Tested Made <br /> Annular Tank#1&2 11 [1 11 Ll El ❑ ❑ <br /> Secondary Pipe #1-87 El El ❑ ❑ El ❑ ElSecondary Pipe#2-91 [I El 11 ED ❑Piping Sump#1-87 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Piping Sump#2-91 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Dispenser Sump#1&2 X ❑ ❑ ❑ ❑ ❑ ❑ 1 ❑ <br /> Dispenser Sump#3&4 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ 1 ❑ ❑ <br /> ❑ 1 ❑ L01 1 ❑ 1 ❑ ❑ I ❑ ❑ <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: a11YDate: February 25,2015 <br />