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SWRCB,January 2002 • S• <br /> SecondaryContainment TestingReport Form JAN 2T bTr- <br /> of <br /> ENVIRONMENTAL HEALTH <br /> This form is intended for use by contractors performing periodic testing of UST secondary containment sysfibW4WW <br /> appropriate pages of this form to report results for all components tested. The completed form, written test procedures, and <br /> printouts from tests(f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Sheriffs Operation Center I Date of Testing: August 27,2015 <br /> Facility Address: 7000 North Michael Canlis Blvd, French Camp,Ca. 95231 <br /> Facility Contact: Dan Mc Ann I Phone: (707)468-3104 <br /> Date Local Agency Was Notified of Testing: 7/13/2015,by Afford-a-Test <br /> Name of Local Agency Inspector(if 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 Training <br /> Manufacturer Component(s) Date Training Expires <br /> Caldwell Systems Piping Sumps/UDC's July, 2017 <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 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Annular Tank#2 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Secondary Pipe#1-87 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Secondary Pipe#2-87-Vapor X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Secondary Pipe#3-Diesel X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Piping Sump#1-87 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Piping Sump#2-Diesel X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Dispenser Sump#1&2-Gas X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Dispenser Sump#3&4-Diesel X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ [1ElLl ❑ ❑ ❑ F] <br /> El ❑ ❑ ❑ ❑ ❑ ❑ <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: �m�sy �tcsacasa Date: August 27,2015 <br />