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1 " <br /> 1 <br /> RECEIVED <br /> SWRCB,January 2002 Page of <br /> Secondary Containment Testing Report Form FEB 0 8 2016 <br /> This form is intended for use by contractors performing periodic testing of UST secondary containr� s ONMEN1/'1L <br /> appropriate pages of this form to report results for all components tested. The completed form, writtejq8q Wopf Mdp.A;rrqa*ir <br /> printouts from tests(if applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Flag City Chevron Date of Testing: January 20,2016 <br /> Facility Address: 6421 Capitol Ave,Lodi,Ca.95242 <br /> Facility Contact: Kiu Phone: (209)334-0975 <br /> Date Local Agency Was Notified of Testing: 12/23/2015,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: ❑CSLB Licensed Contractor X SWRCB Licensed Tank Tester <br /> License Type: Tanh Tester License Number:90-1120/ICC#5246802-UT <br /> Manufacturer Training <br /> 7Caldwell <br /> cturer Component(s) Date TrainingExpires <br /> stems Piping Sum s/UDC's July, 2017 <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> Annular Tank#1 X ❑ ❑ ❑ UDC#1&2 X ❑ ❑ ❑ <br /> Annular Tank#2 X ❑ ❑ ❑ UDC#3&4 X ❑ ❑ ❑ <br /> Annular Tank#3 X ❑ ❑ ❑ UDC#5&6 X ❑ ❑ ❑ <br /> Annular Tank#4 X ❑ ❑ ❑ UDC#7&8 X ❑ ❑ ❑ <br /> Secondary Pipe#1 X ❑ ❑ ❑ UDC#9&10 X ❑ ❑ ❑ <br /> Secondary Pipe#2 X ❑ ❑ ❑ UDC#11&12 X ❑ ❑ ❑ <br /> Secondary Pipe#3 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Secondary Pipe#4 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Piping Sump#1 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Piping Sump#2 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Piping Sump#3 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Piping Sump#4 X ❑ ❑ ❑ r ❑ ❑ ❑ ❑ <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: iiJe�zrizmfn JV-ti�a�rL� Date: January 20,2016 <br />