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SWRCB, 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. U.se 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 (fapplicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: Tracy Valero <br />Date of Testing: September 4, 2013 <br />Facility Address: 2375 Tracy Blvd., Tracy, Ca. 95376 <br />License Type: Tank Tester <br />Facility Contact: Hakam Mission _ <br />Phone: (209) 835-7755 <br />Date Local Agency Was Notified of Testing: <br />9/3/13, by Afford -A -Test, Ok per CUPA <br />Name of Local Agency Inspector (if present during testing): <br />Thuy Tran, REHS <br />X <br />❑ <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: R&D Compliance Testing <br />Technician Conducting Test: Benjamin F. Duncan Jr. <br />Credentials: D CSLB Licensed Contractor X SWRCB Licensed Tank. Tester <br />License Type: Tank Tester <br />License Number: 90-1120/ICC #5246$02 -UT <br />Manufacturer Training <br />Manufacturer Component(s)) Date Training Expires <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />Annular Tank #1 <br />Component <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs Component <br />Made <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />Annular Tank #1 <br />X <br />❑ <br />D <br />I.:;I Dispenser Sump#5&6 <br />X <br />o <br />�_:. <br />0 <br />Annular Tank #2 <br />X <br />❑ <br />❑ <br />❑ Dispenser Sump #7&8 <br />X <br />❑ <br />[ <br />❑ <br />Annular Tank #3 <br />X <br />1:1 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Annular Tank #4 <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Secondary Pipe #1 <br />X <br />❑ <br />C7 <br />❑ <br />[:! <br />[..-1 <br />❑ <br />❑ <br />Secondary Pipe #2 <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Secondary Pipe #3 <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Piping Sump #1 <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Piping Sump #2 <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Piping Sump #3 <br />X <br />❑ <br />o <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Dispenser Sump # 1 &2 <br />X <br />C I <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Dispenser Sump#3&4 <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <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: iv Date: September 4, 2013 <br />