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Ij x <br /> I <br /> gg h <br /> • � !,�t� rias� v <br /> SWRCB,January 2002 Page of- <br /> Secondary Containment Testing Report Form MAR z 8 20-11 <br /> This farm is intended for use by contractors performing periodic testing of UST secondary containrnent�. ,ms, Use the <br /> appropriate a es o thisform to report results or all components tested. The com leted brm, written .r ocedures, and; <br /> pages I I p I p p .1 ���p{'; <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: RAI-Manteca Arco _ _Date_ofTesting: March 1.6,2011 <br /> Facility Address: 1711 East Yosemite Ave., Manteca,Ca. 95336 <br /> Facility Contact: Amba I Phone: (209) 823-4715 <br /> Date Local Agency Was Notified of Testing: 3/11/11 by Afford-A-Test <br /> [=al Agency Inspector(rfpresent 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: 90-1120/ICC H5246802-UT <br /> Manufacturer Training <br /> Manufacturer Component(s) — Date Training Expires <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 ❑ ❑ ❑ Dispenser Sump #7&8 X ❑ ❑ G <br /> Annular Tank#2 X ❑ ❑ ❑ Dispenser Sump #9&10 X ❑ ❑ <br /> Annular Tank#3 X ❑ ❑ ❑ Dispenser Sump #11&12 X ❑ ❑ <br /> Secondary Pipe#1 X ❑ ❑ ❑ Dispenser Sump #13&14 X ❑ ❑ <br /> Secondary Pipe #2 X ❑ ❑ ❑ Dispenser Sump # 15&16 X ❑ ❑_ <br /> Secondary Pipe #3 X I] ❑ ❑ Fill Riser Sump #1 X ❑ ❑ <br /> Piping Sump #1 X ❑ ❑ ❑ Fill Riser Sump 42 X ❑ ❑ <br /> Piping Sump #2 X ❑ ❑ ❑ Fill Riser Sump #3 _ X ❑ ❑ <br /> Piping Sump #3 X ❑ ❑ ❑ _ 0 ❑ ❑ <br /> Dispenser Sump #1&2 X El 0 _ _ _ _ ❑ 110 <br /> Dispenser Sump#3&4 X ❑ ❑ ❑ _ _ 0 0 ❑ L <br /> Dispenser Sump #5&6 X ❑ ❑ 0 0 0 071 <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 fitll compliance with legal requirements <br /> Technician's Signature: �asar�usv (9-alJ $ Date: March 16,201 1 <br />