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RECEIVED <br /> MAR 2 Aa 116 of <br /> SWRCB,January 2002 <br /> Secondary Containment Testing Report FornENVIRONMENTAL <br /> This form is intended for use by contractors performing periodic testing of UST secondary containjgsy%REPiPsi �1 ENT <br /> appropriate pages of this form to report results for all components tested. The completed form, written test procedures, and <br /> printouts from tests(if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Quicki Kleen Car Wash I Date of Testing: February 24,2016 <br /> Facility Address: 707 East Yosemite Ave.,Manteca,Ca.95336 <br /> Facility Contact: Francene Escobar I Phone: (209)823-9159 <br /> Date Local Agency Was Notified of Testing: 2/22/2015,by Afford-A-Test <br /> Name of Local Agency Inspector(if present 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 Expices <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> Secondary Pipe#1 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Secondary Pipe#2 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Secondary Pipe#3 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> El L1 ❑ ❑ El El LJ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,the facts stated in thisdocumentare accurate and in full compliance with legal requirements <br /> Technician's Signature: Date: February 24,2016 <br />