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SWRCB, January 2002 <br />REu.--iVEL <br />ofN9srBf— <br />Secondary Containment Testing Report Form ENV �(� <br />This form is intended for use by contractors performing periodic testing of UST secondary containment sy t ,MENTAL <br />appropriate pages of this form to report results for all components tested The completed form, written test proce ures, a nc�AC�IT <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: Cherokee Lane Service Station/Arco Date of Testing: October 7, 2015 <br />Facility Address: 900 South Cherokee Lane, Lodi, Ca. 95240 <br />Facility Contact: Daljit Grover I Phone: (209) 334-3129 <br />Date Local Agency Was Notified of Testing: 9/11/2015, 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 \ SWRCB Licensed Tank Tester <br />License Type: Tank Tester License Number: 90-1120/ICC#5246802-UC <br />Manufacturer Training <br />Manufacturer Component(s) Date Training Expires <br />Caldwell Systems Piping Sum s/UDC's July, 2017 <br />3. SUMMARY OF TEST RESULTS <br />Component <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Nladc <br />Component <br />Pass Fail Not <br />I Tested <br />Repairs <br />Made <br />Annular Tank #1&2-87-91 <br />X <br />❑ <br />❑ <br />❑ <br />Dispenser Sump #5&6 <br />X ❑ ❑ <br />❑ <br />Annular Tank #3&4 -87 -Diesel <br />X <br />❑ <br />❑ <br />❑ <br />Dispenser Sump #7&8 <br />X ❑ ❑ <br />❑ <br />Secondary Pipe #1-87 <br />X <br />❑ <br />❑ <br />❑ <br />Dispenser Sump #9 <br />X ❑ ❑ <br />0 <br />Secondary Pipe #2-91 <br />X <br />❑ <br />0 <br />❑ <br />Dispenser Sump #9-Satelite <br />X ❑ ❑ <br />❑ <br />Secondary Pipe #3-87 <br />X <br />❑ <br />0 <br />❑ <br />❑ ❑ ❑ <br />❑ <br />Secondary Pipe #4 -Diesel <br />X <br />0 <br />❑ <br />0 <br />❑ ❑ ❑ <br />❑ <br />Piping Sump #1-87 <br />X <br />❑ <br />❑ <br />❑ <br />❑ ❑ ❑ <br />❑ <br />Piping Sump #2-91 <br />X <br />❑ <br />0 <br />❑ <br />❑ ❑ ❑ <br />❑ <br />Piping Sump #3-87 <br />X <br />0 <br />❑ <br />❑ <br />❑ ❑ ❑ <br />❑ <br />Piping Sump #4 -Diesel <br />X <br />❑ <br />❑ <br />❑ <br />❑ ❑ ❑ <br />❑ <br />Dispenser Sump #1&2 <br />X <br />❑ <br />❑ <br />❑ <br />❑ ❑ ❑ <br />❑ <br />Dispenser Sump #3&4 <br />X <br />I ❑ <br />❑ <br />❑ <br />❑ ❑ ❑ <br />❑ <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: October 7. 2015 <br />