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fqE(;L—jVEL <br />SWRCB, January 2002 Page of <br />Secondary Containment Testing Report Form :JUL 13 2015 <br />This form is intended for use by contractors performing periodic testing of UST secondary containment syste"I M E � VNr^ I <br />appropriate pages of this form to report results for all components tested. The completed form, written test procedf es, _,N^,^ T <br />printouts from tests (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory ageiuy. <br />1. FACILITY INFORMATION <br />Facility Name: Super Center Mart I Date of Testing: June 30, 2015 <br />Facility Address: 701 East Charter Way, Stockton, Ca. 95206 <br />Facility Contact: Swaran Chouhan Phone: (209) 467-0305 <br />Date Local Agency Was Notified of Testing: 6/2/2015, by Afford -A -Test <br />Name of Local Agency Inspector (f 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: CSLB Licensed Contractor X SWRCB Licensed Tank Tester <br />License Type: Tank Tester License Number: 90-1120/1CC 45246802 -UT <br />Manufacturer Training <br />Manufacturer Component(s) Date Training Expires <br />Caldwell Systems Piping Sum s/UDC's July, 2016 <br />3. SUMMARY OF TEST RESULTS <br />Component <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />MadeComponent1 <br />, ass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />Annular Tank # 1 &2 <br />X <br />❑ <br />❑ <br />C <br />❑ <br />❑ <br />0 <br />0 <br />Secondary Pipe #1 <br />X <br />❑ <br />❑ <br />❑ <br />0 <br />0 <br />❑ <br />0 <br />Secondary Pipe #2 <br />X <br />❑ <br />❑ <br />0 <br />❑ 1 <br />0 <br />0 <br />0 <br />Piping Sump #1 <br />X❑ <br />❑ <br />❑ <br />0 <br />0 <br />0 <br />0 <br />Piping Sump #2 <br />X❑ <br />❑ <br />❑ <br />0 <br />0 <br />0 <br />0 <br />Dispenser Sump #1 <br />X❑ <br />❑ <br />❑ <br />0 <br />0 <br />0 <br />0 <br />Dispenser Sump #2 <br />X <br />❑ <br />❑ <br />0 <br />0 <br />0 <br />0 <br />Dispenser Sump #3 <br />X <br />0 <br />❑ <br />❑ <br />❑ <br />1 0 <br />0 <br />0 <br />Dispenser Sump #4 <br />X <br />❑ <br />0 <br />❑ <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />❑ <br />0 <br />0 <br />0 <br />0 <br />❑ <br />❑ <br />❑ <br />❑ <br />0 <br />0 <br />0 <br />C <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: Date: June 30, 2015 <br />