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SWRCB,January 2002 Page of <br /> Secondary Containment Testing Report Form <br /> 7hisform 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 foi all componenlVested. The completed form, written test procedures, and <br /> printouts from tests(fapplicable), should be provided to the facility owner'operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: SRH Food&Gas Mart I Date of Testing: March 7,2018 <br /> Facility Address: 749 East Charter ay,Stockton,Ca.95206 <br /> Facility Contact: Johnny I Phone: (209)465-8979 <br /> Date Local Agency Was NotiQed of Testing: 2/13/2018 <br /> Name of Local Agency Inspector(fpresent during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Afford-a-test <br /> Technician Conducting Test: Benjamin F. Duncan Jr./ICC :x5246802-UT <br /> Credentials: X CSLB Licensed Contractor X SWRCB Licensed Tank Tester <br /> License Type: A License Number: CSLB Lic. -341;75;SWBCB Lia 490-1120 <br /> Manufacturer Trainine <br /> Manufacturer _ _ Component(s) Date Training Expires <br /> Caldwell Systems _ Piping; Sumps/UDC's July 5, 2020 <br /> _ 3. SUMMARY OF TEST RESULTS <br /> Com onem Pass Fail Not Repairs Not Repairs <br /> 1 Tested Made Component Pass Fail Tested Made <br /> Annular Tank#I X ] CI Dispenser Sump#7&8 X <br /> Annular Tank 42 X ❑ L ❑ LI LC] C; <br /> Annular Tank#3 X L ❑ L ❑ ❑ ❑ <br /> Secondary Pipe#I X Ci L L ❑ ❑ ❑ L <br /> Secondary Pipe#2 X n, L L ❑ ❑ L ❑ <br /> Secondary Pipe#3 X ❑ J ❑ <br /> Piping Sump#1 X ❑ ❑ i7 ❑ L7 <br /> Piping Sum #2 X ❑ ❑ ❑ ❑ <br /> Piping Sum #3 X t ❑ ❑ ❑ <br /> Dispenser Sump#1&2 X ❑ C ❑ ❑ <br /> Dispenser Sump#3&4 X 1,, ❑ ❑ 71 <br /> Dispenser Sump #5&6 X L ❑ ❑ L L <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. <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,�grrthefacis stateddiinn thisdocumentare accurate and in full compliance with legal requirements <br /> Technician's Signature:�,�rajtattrabr s� ..l m aawok Date: March 7.20 18 <br />