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SWRCB,January 2002 FF{{ <br /> Secondary Containment Testing Report Form <br /> This form is intended for use by contractors performing periodic testing of UST secondary containment systems. (j�hey 3 2015 <br /> appropriate pages of this form to report results for all components tested. The completed form, written test procedures, and <br /> printouts from tests(:f applicable),should be provided to the facility owner/operator for submittal to the local regulatory1*e1rcyNT A) <br /> 1. FACILITY INFORMATION <br /> Facility Name: Delta Arco I Date of Testing: June I6,2015 <br /> Facility Address: 440 West Charter Way,Stockton,Ca.95206 <br /> Facility Contact: Major Singh Phone: (209)465-2487 <br /> Date Local Agency Was Notified of Testing: 6/5/2015,by Afford-A-Test <br /> Name of Local Agency Inspector(f present during testing): *Stacy Rivera,Senior RENS <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: 90-11203CC#5246802-UT <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 /> Not Repairs Not Repairs <br /> Component Nass Fail Tested Made 1O1t"'ncnt Pass Pail Tested Made <br /> Annular Tank#1 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Annular Tank#2 X 1 ❑ ❑ 0 0 0 0 <br /> Secondary Pipe#1 X I ❑ ❑ ❑ 0 0 0 ❑ <br /> Secondary Pipe#2 X 0 0 ❑ 0 0 0 0 <br /> Piping Sump#1 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Piping Sump#2 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Dispenser Sump#1&2 X 1 ❑ ❑ ❑ ❑ 0 ❑ ❑ <br /> Dispenser Sump#3&4 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Dispenser Sump#5&6 X ❑ ❑ ❑ 0 ❑ ❑ ❑ <br /> Dispenser Sump#7&8 X 0 0 0 0 0 0 0 <br /> Dispenser Sump#9&10 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Dispenser Sump#11&12 X ❑ ❑ ❑ ❑ ❑ ❑ C� <br /> If hydrostatic testing was performed,describe what was done with the water atter completion of tests: <br /> Test fluid supplied and recovered for reuse by,R& D Compliance Testing. <br /> *Spot Check by Inspector Stacy Rivera,Senior RENS. Not present for all 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: 9rwwardX. Date: June 16,2015 <br />