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SWRCB,January 2002 Page of Secondary Containment Testing Report Form This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the appropriate pages of this form to report results for all components tested. The completed form, written test procedures, and printouts from tests(f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. 1. FACILITY INFORMATION Facility Name: Express Mart 76 1 Date of Testing: May 21,2012 Facility Address: 419 South Main St.,Manteca, Ca.95336 Facility Contact: Bobby or Simmi I Phone: (209)239-7978 Date Local Agency Was Notified of Testing: 5/7/2012 Name of Local Agency Inspector(fpresent during testing): 2. TESTING CONTRACTOR INFORMATION Company Name: R&D Compliance Testing Technician Conducting Test: Benjamin F.Duncan Jr. Credentials: ❑CSLB Licensed Contractor X SWRCB Licensed Tank Tester License Type: Tank Tester License Number: 90-1120/ICC#5246802-UT Manufacturer Training Manufacturer Component(s) Date Training Expires 3. SUMMARY OF TEST RESULTS Component Pass Fail Not Repairs Component Pass Fail Not Repairs Tested Made Tested Made Annular Tank#I X ❑ ❑ ❑ ❑ ❑ ❑ ❑ Annular Tank#2 X 0 ❑ ❑ 0 ❑ ❑ ❑ Annular Tank#3 X 0 0 ❑ 0 ❑ 0 ❑ Secondary Pipe#1 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ Secondary Pipe #2 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ Secondary Pipe#3 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ Piping Sump#1 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ Piping Sump#2 X ❑ 0 ❑ ❑ ❑ ❑ ❑ Piping Sump#3 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ Dispenser Sump#1&2 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ Dispenser Sump#3&4 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ If hydrostatic testing was performed,describe what was done with the water after completion of tests: Test Fluid Supplied and Recovered for reuse by,R&D Compliance Testing. CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING To the best of my knowledge,the facts stated in this document are accurate and in full compliance with legal requirements Technician's Signature: Date:Date: May 21,2012