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0 <br />w <br />SWRCB, January 2002 Q fre of_ <br />DLII :1 . 9 <br />Secondary Containment Testing Report Form <br />This form is intended for use by contractors performing periodic testing of UST secondap!.containment systems. Use the <br />appropriate pages ofthis form to report results for all components tested The complete7Varm, written test procedures, and <br />printouts from tests (ifopplicable), should be provided to the facility owner/operatorfor submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: Orlando's Market I Date of Testing: June 21, 2017 <br />Facility Address: 18754 East Hwy 26, Linden, Ca. 95236 <br />Facility Contact: Sam or Jerry I Phone: (209) 887-1100 <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 <br />License Number: 90-1120/ICC #5246802 -UT <br />Manufacturer Training <br />Manufacturer Component(s) Date Training Expires <br />Caldwell Systems Piping Sum s/UDC's July 30, 2017 <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />3. SUMMARY OF TEST RESULTS <br />Component <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />Component <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />Annular Tank #1 <br />X <br />❑ <br />❑ <br />❑ <br />Dispenser Sump #7&8 <br />X <br />❑ <br />❑ <br />❑ <br />Annular Tank #2&3 <br />X <br />❑ <br />❑ <br />❑ <br />Dispenser Sump 49&10 <br />X <br />❑ <br />❑ <br />❑ <br />Secondary Pipe #1 <br />X <br />❑ <br />❑ <br />❑ <br />Dispenser Sump #11&12 <br />X <br />❑ <br />❑ <br />❑ <br />Secondary Pipe #2 <br />X <br />❑ <br />❑ <br />❑ <br />Fill Riser Sump #1 <br />X <br />❑ <br />❑ <br />❑ <br />Secondary Pipe #3 <br />X <br />❑ <br />❑ <br />❑ I <br />Fill Riser Sump #2 <br />X <br />❑ <br />❑ <br />❑ <br />Secondary Pipe #4 <br />X 1 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Piping Sump #1 <br />X 1 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Piping Sump 42 <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Piping Sump #3 <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Dispenser Sump #1&2 <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Dispenser Sump#3&4 <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Ll <br />❑ <br />Dispenser Sump#5&6 <br />X <br />—, <br />Ll11EJ <br />Ll <br />11❑ <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:Date: June 21. 2017 <br />