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-'E"VE <br /> 2 7 W� <br /> SWRCB,January 2002 JUL Page_of <br /> Secondary Containment Testing Report FormENV,Roj,�' E"TAL <br /> This form is intended for use by contractors performing periodic testing of UST secondary containment ly7sRalis'. 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 ownerloperatorfor submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Bank of Stockton I Date of Testing: June 27,2018 <br /> Facility Address: 1941 East Lockheed Court,Gate 16, Stockton,Ca.95206 <br /> Facility Contact: Norman White or John Kluenker 7 Phone: (209)969-1047 <br /> Date Local Agency Was Notified of Testing: 6/13/2018 <br /> Name of Local Agency Inspector(if present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Afford-a-test <br /> Technician Conducting Test: Benjamin F.Duncan JrACC#5246802-UT <br /> Credentials: X CSLB Licensed Contractor X SWRCB Licensed Tank Tester <br /> License Type: A I License Number: CSLB Lic.#341375/SWRCB Lic.#90-1120 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> I Caldwell Systems Piping Sum /Transition Piping Sump July 5, 2020 <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 X [I El 0 11 [1 El 0 <br /> Secondary Pipe-Main X 11 [1 0 LJ D El El <br /> Secondary Pipe-Return X El El El [I El 0 [1 <br /> Secondary Pipe-Vent x 0 0 0 El [1 0 11 <br /> Piping Sump X El 0 11 El 0 El 11 <br /> Transition Piping Sump X 11 [1 0 E 0 [1 11 <br /> 11 11 El 11 El El [1 11 <br /> [I El El El 11 11 <br /> El 0 El 11 0 0 <br /> 0 El El [I El 0 El E <br /> E El 0 El El L1 [I El <br /> 11 El 11-1-0 11 El 11 0 <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. <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: Date: June 27,2018 <br />