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e of , <br /> SWRCB,January 2002 Page <br /> Secondary Containment Testing Report Form NOV 10 2014 <br /> This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the <br /> appropriate pages of this form to report results for all components tested. The completed form, wriEt¢1yY�5R:frocedures,and I TH <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: E.F.Kludt&Son's Date of Testing: October 28,2014 <br /> Facility Address: 1126 East Pine Street,Lodi,Ca.95241 <br /> Facility Contact: Steve Kludt Phone: (209)368-0634 <br /> Date Local Agency Was Notified of Testing: 9/17/2014,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 Expires <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> Annular Tank#1 X ❑ ❑ ❑ Secondary Pipe #8 X ❑ ❑ ❑ <br /> Annular Tank#2 X ❑ ❑ ❑ Piping Sump#1 X ❑ ❑ ❑ <br /> Annular Tank#3 X ❑ ❑ ❑ Piping Sump#2 X ❑ ❑ LI— <br /> Annular <br /> Annular Tank#4 X ❑ ❑ ❑ Piping Sump#3 X ❑ ❑ ❑ <br /> Annular Tank#5 X I ❑ ❑ ❑ 1 Piping Sump#4 X ❑ ❑ ❑ <br /> Secondary Pipe 41 X ❑ ❑ ❑ Piping Sump#5 X ❑ ❑ ❑ <br /> Secondary Pipe #2 X ❑ ❑ ❑ UDC#11&12M/13&14DD X ❑ ❑ ❑ <br /> Secondary Pipe #3 X ❑ ❑ ❑ UDC#11&10 Satellite X ❑ ❑ ❑ <br /> Secondary Pipe #4 X ❑ ❑ ❑ UDC#10&9 M X ❑ ❑ ❑ <br /> Secondary Pipe #5 X ❑ ❑ ❑ UDC# 9 Satellite X ❑ ❑ ❑ <br /> Secondary Pipe #6 X ❑ ❑ ❑ UDC#7&8 Auto Diesel X ❑ ❑ ❑ <br /> Secondary Pipe#7 X ❑ ❑ ❑ UDC Kerosene/110 Octane I X1 ❑ I ❑ 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,fthe facts statedin this <br /> document are accurate and in full compliance with legal requirements <br /> Technician's Signature: R►a�m .T. slJ Date: October 28.2014 <br />