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SWRCB, January 2002 Page of Secondary Containment Testing Report Form This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the appropriate pages of this form to report results for all components tested. The completed form, written test procedures, and printouts from tests (f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. 1. FACILITY INFORMATION Facility Name: Stockton Auto Center Car Wash Date of Testing: January16, 2013 Facility Address: 3434 East Hammer Lane, Stockton, Ca. 95212 Facility Contact: Chris Buscaglia I Phone: (209) 956-4040 Date Local Agency Was Notified of Testing: 1/10/13 by Afford -A -Test Name of Local Agency Inspector (f present during testing): Component Pass Fail Not Tested Repairs Made Component Pass Fail Not Repairs Tested Made Annular Tank #1-87 X ❑ ❑ ❑ Dispenser Sump #3&4 X ❑ ❑ ❑ Annular Tank #2&3 -91 -Diesel X ❑ ❑ ❑ Dispenser Sump #5&6 X ❑ ❑ ❑ Secondary Pipe #1-87 X ❑ ❑ ❑ Fill Riser Sump #1-87 X ❑ ❑ ❑ Secondary Pipe #2-91 X ❑ ❑ ❑ Fill Riser Sump #2-91 X ❑ ❑ ❑ Secondary Pipe #3 -Diesel X ❑ ❑ ❑ Fill Riser Sump #3 -Diesel X ❑ ❑ ❑ Secondary Pipe #4 -Diesel -Vent X ❑ ❑ ❑ ❑ ❑ ❑ ❑ Secondary Pipe #5 -Gasoline Vapor X ❑ ❑ ❑ ❑ ❑ ❑ ❑ STP Piping Sump # 1-87 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ STP Piping Sump #2-91 X ❑ ❑ ❑ ❑ ❑ ❑ [1 STP Piping Sump #3 -Diesel X ❑ ❑ ❑ ❑ ❑ ❑ ❑ Vent Box Piping Sump X ❑ ❑ ❑ ❑E01❑ El Dispenser Sump # 1 &2 X El El 11 El ❑ ❑ If hydrostatic testing was performed, describe what was done with the water after completion of tests: Test Fluid Supplied and recovered for reuse by, R&D Compliance Testing. CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING To the best of my knowledge, the facts stated in this document are accurate and in full compliance with legal requirements Technician's Signature:Date: January 16, 2013