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SWRCB, January 2002 <br />Secondary Containment Testing Report Form <br />Page of <br />This form is intended for use by contractors performing periodic testing of UST secondary containment systems. 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 (f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: Bill's 76 1 Date of Testing: January 9, 2012 <br />Facility Address: 633 East Victor Rd., Lodi, Ca. 95240 <br />Facility Contact: Bill Padda Phone: (209) 367-1795 <br />Date Local Agency Was Notified of Testing: 12/30/11 by Afford -A -Test <br />Name of Local Agency Inspector (f present during testing): <br />2. TESTING CONTRACTOR INFORMATION <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: iffmyaww� Jr_ffu � Date: January 9, 2012 <br />3. SUMMARY OF TEST <br />RESULTS <br />Component <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />Component <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />Annular Tank #1 <br />❑ <br />❑ <br />X <br />❑ <br />Dispenser Sump #7&8 <br />X <br />❑ <br />❑ <br />❑ <br />Annular Tank #2 <br />❑ <br />❑ <br />X <br />❑ <br />0 <br />0 <br />❑ <br />0 <br />Annular Tank #3 <br />❑ <br />1 ❑ <br />X <br />❑ <br />0 <br />❑ <br />❑ <br />0 <br />Secondary Pipe #I <br />X <br />❑ <br />0 <br />0 <br />0 <br />0 <br />0 <br />❑ <br />Secondary Pipe #2 <br />X <br />0 <br />❑ <br />❑ <br />0 <br />0 <br />0 <br />0 <br />Secondary Pipe #3 <br />X <br />❑ <br />0 <br />❑ <br />0 <br />0 <br />0 <br />0 <br />Piping Sump #1 <br />X <br />❑ <br />❑ <br />❑ <br />0 <br />0 <br />0 <br />0 <br />Piping Sump #2 <br />X <br />❑ <br />❑ <br />❑ <br />0 <br />0 <br />❑ <br />0 <br />Piping Sump #3 <br />X <br />❑ <br />❑ <br />❑ <br />0 <br />0 <br />❑ <br />0 <br />Dispenser Sump #1&2 <br />X <br />❑ <br />❑ <br />❑ <br />0 <br />0 <br />❑ <br />0 <br />Dispenser Sump #3&4 <br />X <br />❑ <br />❑ <br />❑ <br />0 <br />0 <br />0 <br />0 <br />Dispenser Sump #5&6 <br />X <br />❑ <br />❑ <br />❑ <br />0 <br />0 <br />❑ <br />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 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: iffmyaww� Jr_ffu � Date: January 9, 2012 <br />