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S WRCB, January 2002 Secondary Containment Testing Report Form This form is intended for use by contractors performing periodic testing of UST secondary containment sysDU OSA4010 appropriate pages of this form to report results for all components tested. The completed form, writt r printouts from tests (if applicable), should be provided to the facility owner/operator for submittal to�H 1. FACILITY INFORMATION Facility Name: Thornton 76 1 Date of Testing: September 8, 2010 Facility Address: 8606 Thornton Rd., Stockton, Ca. 95209 Facility Contact: Amarjit I Phone: (209) 478-8959 Date Local Agency Was Notified of Testing: 8/27/10 Name of Local Agency Inspector (fpresent during testing): 2. TESTING CONTRACTOR INFORMATION Company Name: R&D Compliance Testing Technician Conducting Test: Benjamin F. Duncan Jr. Credentials: ❑ CSLB Licensed Contractor X SWRCB Licensed Tank Tester License Type: Tank Tester License Number: 90-1120/ICC #5246802 -UT Manufacturer Training Manufacturer Component(s) Date Training Expires 3. SUMMARY OF TEST RESULTS Component Pass Fail Not Tested Repairs Component Made Pass Fail Not Repairs Tested Made Annular Tank #1 X ❑ ❑ ❑ 0 ❑ ❑ Annular Tank #2 X ❑ ❑ ❑ 0 0 0 _ Annular Tank #3 X ❑ ❑ ❑ ❑ 0 0 Secondary Pipe #1 X ❑ ❑ ❑ 0 ❑ 0 Secondary Pipe #2 X ❑ ❑ ❑ ❑ ❑ 0 Secondary Pipe #3 X ❑ ❑ ❑ ❑ ❑ 0 Piping Sump #1 X ❑ ❑ ❑ ❑ ❑ 0 Piping Sump #2 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ Piping Sump #3 X ❑ ❑ ❑ ❑ ❑ ❑ 0 Dispenser Sump #1&2 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ Dispenser Sump#3&4 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ 1 ❑ ❑ ❑ ❑ ❑ 0 If hydrostatic testing was performed, describe what was done with the water after completion of tests: Test Fluid Supplied and recovered for reuse by, R&D Compliance Testing. _ CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING To the best of my knowledge, the facts stated in this documentTe e accurate and in full compliance with legal requirements q -8-2 Technicians Signatur`--�- z — Date: