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i r <br /> Page_of <br /> SWRCB,January 2002 <br /> Secondary Containment Testing Report Form <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 farm, written test procedures, and <br /> printouts from tests(if applicable),should be provided to the facility owner/operator far submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Wine Country 76 1Date of Testing: 12/20/2011 <br /> Facility Address: 1111 East Kettleman Road,Lodi,Ca.95240 <br /> Facility Contact: Sandeep Singh Phone: (209)369-3633 <br /> Date Local Agency Was Notified of Testing : 11/03/1 I 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: C 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 Traininp Expires <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Repairs WOO <br /> airs <br /> Component Pass Fail P Component ade <br /> Tested Made <br /> Annular Tank#1 X ❑ ❑ ❑ <br /> Annular Tank#2&3 X ❑ ❑ ❑ <br /> Secondary Pipe#1 X ❑ ❑ ❑Secondary Pipe#2 X ❑ ❑ ❑ ❑Secondary Pipe#3 X ❑ ❑ ❑ ❑Piping Sump #1 X ❑ ❑ ❑ ❑ <br /> Piping Sump #2 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Piping Sump #3 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Dispenser Sump #1&2 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Dispenser Sump#3&4 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Dispenser Sump#5&6 X ❑ ❑ I ❑ ❑ ❑ ❑ ❑ <br /> Dispenser Sump#7&8 X ❑ ❑ 1 ❑ ❑ ❑ ❑ 1 ❑ <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 statedinthis document are accurate and in full compliance with legal requirements <br /> %� <br /> Technician's Signature: kn ✓ Date: December 20.2011 <br />