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� f <br /> R E <br /> SWRCB,January 2002 $ja <br /> Secondary Containment Testing Report Form <br /> This form is intended for use by contractors performing periodic testing of UST secondary containn mat§. Esc thh <br /> appropriate pages of this form to report results for all components tested The completed form, written testdtres, <br /> printouts from tests(if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Wilson Way Chevron I Date of Testing: October 19,2017 <br /> Facility Address: 437 North Wilson Way,Stockton,Ca.94205 <br /> Facility Contact: Aman or Paul Judge Phone: (209)942-2344 <br /> Date Local Agency Was Notified of Testing: 9/12/2017 <br /> Name of Local Agency Inspector(f present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Afford-a-test <br /> Technician Conducting Test: Benjamin F.Duncan Jr./ICC#5246802-UT <br /> Credentials: X CSLB Licensed Contractor X SWRCB Licensed Tank Tester <br /> License Type: A License Number: CSLB Lic.#341375/SWRCB Lic.#90-1120 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> Caldwell Systems Piping Sum s/UDC's/Fill Riser Sums 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#1 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Annular Tank#2 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Secondary Pipe#1 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Secondary Pipe#2 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Piping Sump#1 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Piping Sump#2 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Dispenser Sump#1&2 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Dispenser Sump#3&4 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Dispenser Sump#5&6 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Dispenser Sump#7&8 X ❑ ❑ I ❑ ❑ ❑ ❑ ❑ <br /> Fill Riser Sump#1 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> =ill Sump#2 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <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:Wr-aw� �lrt2c�w Date: October 19,2017 <br />