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Y. -------------------------------- - - -------------------------- <br /> S W RCB,January 2002 Page of <br /> Secondary Containment Testing Report Form <br /> This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the <br /> appropriate pages of this form to report results for all components tested The completed form,written test procedures, and <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: ABC Food Mart I Date of Testing: May 22,2013 <br /> Facility Address: 713 North Eldorado Street,Stockton,Ca.95202 <br /> Facility Contact: Vic Judge or Harpreet Singh I Phone: (209)465-5222 <br /> Date Local Agency Was Notified of Testing: 4/20/13,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 X SWRCB Licensed Tank Tester <br /> License Type: Tank Tester License Number:90-11201ICC <br /> #5246jDate <br /> Manufacturer Trainin-, <br /> in Expires <br /> Manufacturer Com nent(s) <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Repairs Not Repairs <br /> Component Pass Fail Tested Made Component Pass Fail Tested Made <br /> Secondary Pipe#1 X ❑ ❑ ❑ Dispenser Sump#3&4 X ❑ ❑ ❑ <br /> Secondary Pipe#2 X ❑ ❑ ❑ Dispenser Sump#5&6 X ❑ ❑ ❑ <br /> Secondary Pipe#3 X ❑ ❑ ❑ Dispenser Sump#7&8 X ❑ ❑ ❑ <br /> Secondary Pipe#4 X ❑ ❑ ❑ Dispenser Sump#9&10 X ❑ ❑ ❑ <br /> Secondary Pipe#5 X ❑ ❑ ❑ Dispenser Sump#I 1&12 X ❑ ❑ ❑ <br /> Secondary Pipe#6 X ❑ ❑ ❑ Fill Riser Sump#1 X ❑ ❑ ❑ <br /> Secondary Pipe#7 X 0 ❑ ❑ Fill Riser Sump#2 X ❑ 0 ❑ <br /> Piping Sump#1 X ❑ ❑ ❑ Fill Riser Sump#3 X ❑ ❑ ❑ <br /> Piping Sump#2 X ❑ ❑ ❑ ❑ ❑ 1 ❑ ❑ <br /> Piping Sump#3 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Vent Box Sump X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Dispenser Sump#1&2 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <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 leVECEI V ED <br /> 1 Technician's Signature: ,ifJeo �/q zcaw G May22,2013 MAR. `� 0 <br /> EHVIRODNMR NTAL <br />