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1 <br /> RECENED <br /> SWRCB,January 2002 MP <br /> APq%--- <br /> Secondary Containment Testing Report Form <br /> MENTAL <br /> This form is intended for use by contractors performing periodic testing of UST secondary containment systeEN � TP.� <br /> appropriate pages of this form to report results for all components tested The completed form, written test procedzrr�s' 'n <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: Village West Marina I Date of Testing: March 19,2018 <br /> Facility Address: 6649 Embarcadero Drive,Stockton,Ca.95219 <br /> Facility Contact: Tim Fontaine I Phone: (209)951-1551 <br /> Date Local Agency Was Notified of Testing: 3/1/2018 <br /> Name of Local Agency Inspector(if present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Afford-a-test <br /> Technician Conducting Test: Benjamin F.Duncan Jr./ICC#5246802-UT <br /> Credentials: X CSLB Licensed Contractor X SWRCB Licensed Tank Tester <br /> License Type: A I License Number: CSLB Lie.#341375/SWRCB Lic. 00-1120 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> Caldwell Systems Piping Sumps/Transitions Piping Sum s/UDC's July 5,2020 <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 ❑ 0 ❑ ❑ ❑ ❑ ❑ <br /> Annular Tank#2 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Secondary Pipe#1 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Secondary Pipe#2 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Piping Sump#1 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Piping Sump#2 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Transition Piping Sump#1 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Transition Piping Sump#2 X ❑ ❑ ❑ ❑ ❑ ❑ 1 ❑ <br /> Dispenser Sump#1 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Dispenser Sump#2 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Dispenser Sump#3 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> El 1:1 F1 ❑ ❑ ❑ ❑ ❑ <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,the facts stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: � Date: March 19,2018 <br />