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RECEIVED <br /> SWRCB,January 2002 MAR ffg,.of <br /> Secondary Containment Testing Report Form 44 <br /> This form is intended for use by contractors performing periodic testing of UST secondary contai &UP"WAL <br /> appropriate pages of thisform to report resultsfor all components tested. The completed form, writAPUMT&WNT <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: Food Mart Gasoline Date of Testing: 11/15/2016 <br /> Facility Address: 2185 East Fremont Street,Stockton,Ca.95205 <br /> Facility Contact: Joginder Lal Phone: (209)547-1700 <br /> Date Local Agency Was Notified of Testing: 10/10/2016,by Afford-A-Test <br /> Name of Local Agency Inspector(rf 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: L CSLB Licensed Contractor X SWRCB Licensed Tank Tester <br /> License Type: Tank Tester License Number: 90-1120/ICC#5246802-UT <br /> Manufacturer Trainine <br /> Manufacturer Component(s) Date Training Expires <br /> Caldwell Systems Piping Sum s/UDC's July 30, 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#1,2&3 X ❑ ❑ ❑ Fill Riser Sump#2 X ❑ ❑ ❑ <br /> Secondary Pipe#1 X ❑ ❑ ❑ Fill Riser Sump#3 X ❑ ❑ ❑ <br /> Secondary Pipe #2 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Secondary Pipe#3 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Piping Sump#1 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Piping Sump#2 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Piping Sump#3 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Dispenser Sump#1&2 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Dispenser Sump#3&4 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Dispenser Sump#5&6 X 1 ❑ ❑ 1 ❑ ❑ 1 ❑ ❑ ❑ <br /> Dispenser Sump#7&8 X ❑ ❑ I ❑ ❑ Elj ❑ I ❑ <br /> Fill Riser Sump #1 X 1 ❑ ❑ I ❑ ❑ ❑ I ❑ I ❑ <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: Wylj r..�sz �� Date: November 15,2016 <br />