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RECE ED <br /> SWRCB,January 2002 SEM-rkp <br /> Secondary Containment Testing Report Form ENVIRONMENTAL HEALTH <br /> This form is intended for use by contractors performing periodic testing of UST secondary containment systems?EBWIMVICES <br /> appropriate pages ofthis form to report results for all components tested The completedform, written test procedures, and <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: Arch Road AmPm I Date of Testing: June 20,2017 <br /> Facility Address: 4855 South Highway 99,Stockton,Ca.95215 <br /> Facility Contact: Gil I Phone: (209)481-7445 <br /> Date Local Agency Was Notified of Testing: 5/4/2017,by Afford-A-Test <br /> Name of Local Agency Inspector(ifpresent 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 Com onent s Date Training Expires <br /> Caldwell Systems Piping Sum s/UDC's July 30, 2017 <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Comonent Pass Fail Not Repairs <br /> p <br /> Tested Made Tested Made <br /> Annular Tank#1 X ❑ ❑ ❑ Dispenser Sump#7&8 X ❑ ❑ ❑ <br /> Annular Tank#2 X ❑ ❑ ❑ Dispenser Sump#9&10 X ❑ ❑ ❑ <br /> Annular Tank#3 X ❑ ❑ ❑ Dispenser Sump#11&12 X ❑ ❑ ❑ <br /> Secondary Pipe #1 X ❑ ❑ ❑ Dispenser Sump#13&14 X ❑ ❑ ❑ <br /> Secondary Pipe #2 X I ❑ ❑ ❑ Dispenser Sump#15&16 X ❑ ❑ ❑ <br /> Secondary Pipe#3 X ❑ ❑ ❑ Dispenser Sump#17&18 X ❑ ❑ ❑ <br /> Piping Sump#1 X ❑ ❑ dE] <br /> ❑ ❑ El 11Piping Sump#2 X El ❑ ❑ El 11Piping Sump#3 X ❑ ❑ ❑ El Ll El <br /> Dispenser Sump#1&2 X [10 Ll [1 ❑ 11Dispenser Sump#3&4 X ❑ [1 ❑ ❑ El ElDispenser Sump#5&6 X ❑ El ❑ ❑ ❑ ❑ <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 <br /> iin'this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: Rnfa»s11J- J: _!/lutaafa Date: June 20.2017 <br />