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0 REQ <br />IVJ�D <br />SWRCB, January 2002 age o <br />Secondary Containment Testing Report Form JAN 0 6 2014 <br />This form is intended for use by contractors performing periodic testing of UST secondary containmen <br />appropriate pages of this form to report results for all components tested. The completed form, writte f&N TA L <br />printouts from tests (f applicable), should be provided to the facility owner/operator for submittal to the <br />1. FACILITY INFORMATION <br />Facility Name: Mossdale Arco Date of Testing: March 28, 2013 <br />Facility Address: 444 Mossdale Rd., Lathrop, Ca. 95330 <br />Facility Contact: Paul Singh I Phone: (209) 823-4715 <br />Date Local Agency Was Notified of Testing: 3/26/12 by Afford -A -Test <br />Name of Local Agency Inspector (f 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: 90-1120/ICC #5246802 -UT <br />Manufacturer Trainine <br />Manufacturer Component(s) Date Training Expires <br />3. SUMMARY OF TEST RESULTS <br />Component <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs Component <br />Made <br />Pass Fail Not <br />Tested <br />Repairs <br />Made <br />Annular Tank #1 -87 -91 -Diesel <br />X <br />❑ <br />❑ <br />❑ Dispenser Sump #11&12 <br />X ❑ ❑ <br />❑ <br />Secondary Pipe #1-87 <br />X <br />❑ <br />❑ <br />❑ <br />❑ ❑ ❑ <br />❑ <br />Secondary Pipe #2-91 <br />X <br />❑ <br />❑ <br />0 <br />❑ ❑ ❑ <br />❑ <br />Secondary Pipe #3 -Diesel <br />X <br />❑ <br />❑ <br />❑ <br />❑ ❑ ❑ <br />❑ <br />Piping Sump #1-87 <br />X <br />❑ <br />❑ <br />❑ <br />❑ ❑ ❑ <br />❑ <br />Piping Sump #2-91 <br />X <br />❑ <br />❑ <br />❑ <br />❑ ❑ ❑ <br />❑ <br />Piping Sump #3 -Diesel <br />X <br />❑ <br />❑ <br />❑ <br />❑ ❑ ❑ <br />❑ <br />Dispenser Sump #1&2 <br />X <br />❑ <br />❑ <br />❑ <br />❑ ❑ ❑ <br />❑ <br />Dispenser Sump#3&4 <br />X <br />❑ <br />❑ <br />❑ <br />❑ ❑ ❑ <br />❑ <br />Dispenser Sump#5&6 <br />X <br />❑ <br />❑ <br />❑ <br />❑ ❑❑ <br />11Dispenser <br />Sump #7&8 <br />X <br />El <br />El <br />❑ ❑ ❑ <br />❑ <br />Dispenser Sump #9&10 <br />X <br />El <br />El <br />El <br />El El❑ <br />❑ <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: mea Date: March 28, 2013 <br />-�a <br />