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SWRCB, January 2002 Page of <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 form, written test procedures, and <br />printouts from tests (f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: Super Center Mart Date of Testing: June 12, 2012 <br />Facility Address: 701 East Charter Way, Stockton, Ca. 95206 <br />Facility Contact: Swaran Chouhan I Phone: (209) 467-0305 <br />Date Local Agency Was Notified of Testing: 6/7/12, by Afford -A -Test <br />[Name of Local Agency Inspector (if present during testing): <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: R&D Compliance Testing <br />Technician Conducting Test: Benjamin F. Duncan Jr. <br />Credentials: -1 CSLB Licensed Contractor X SWRCB Licensed Tank Tester <br />License Type: Tank Tester License Number: 90-1120/ICC #5246802-L17' <br />Manufacturer Training <br />Manufacturer Component(s) Date Training Expires <br />3. SUMMARY OF TEST RESULTS <br />Component <br />Nass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />('umponcnt Pass <br />Fail <br />*Not <br />'1'csted <br />Repairs <br />Nladc <br />Annular Tank #1&2 <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Secondary Pipe #1 <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Secondary Pipe #2 <br />X <br />❑ <br />1 ❑ <br />❑ <br />0 <br />❑ <br />❑ <br />❑ <br />Piping Sump #1 <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Piping Sump #2 <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Dispenser Sump #1 <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Dispenser Sump #2 <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Dispenser Sump #3 <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />0 <br />❑ <br />❑ <br />Dispenser Sump #4 <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />o <br />❑ <br />❑ <br />❑ <br />0 <br />0 <br />❑ <br />❑ <br />0 <br />❑ <br />❑ <br />0 <br />0 <br />El <br />117 <br />0 <br />[1 <br />id <br />0 <br />❑ <br />❑ <br />0 <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: �, �r��� Date: June 12, 2012 <br />