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SWRCB, January 2002 0 R E CZLVE D <br />Secondary Containment Testing Report Form MAY 2 1 2013 <br />This form is intended for use by contractors performing periodic testing of UST secondary containment s stems. Use the <br />appropriate pages of this form to report results for all components tested. The completed form, writte <br />printouts from tests (if applicable), should be provided to the facility owner/operator for submittal to the VtEALjr40wARqg#VFjT <br />1. FACILITY INFORMATION <br />Facility Name: Quick N Stop Mart I Date of Testing: April 10, 2013 <br />Facility Address: 2057 South El Dorado Street, Stockton, Ca. 95206 <br />Facility Contact: Dhillon I Phone: (209) 463-6474 <br />Date Local Agency Was Notified of Testing: 4/3/2013, by Afford -A -Test <br />Name of Local Agency Inspector (f 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-UC <br />Manufacturer Training <br />Manufacturer Component(s) Date Training Expires <br />3. SUMMARY OF TEST RESULTS <br />Component <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />Component Pass Fail <br />Not <br />Tested <br />Repairs <br />Made <br />Annular Tank # 1 -9 1 &2-87 <br />X <br />❑ <br />❑ <br />❑ <br />❑ ❑ <br />❑ <br />❑ <br />Secondary Pipe #1-91 <br />X <br />❑ <br />❑ <br />❑ <br />❑ ❑ <br />❑ <br />❑ <br />Secondary Pipe #2-87 <br />X <br />❑ <br />❑ <br />❑ <br />❑ ❑ <br />❑ <br />❑ <br />Piping Sump #1-91 <br />X <br />❑ <br />❑ <br />❑ <br />❑ ❑ <br />❑ <br />❑ <br />Piping Sump #2-87 <br />X <br />❑ <br />❑ <br />❑ <br />❑ ❑ <br />❑ <br />❑ <br />Dispenser Sump #1&2 <br />X <br />❑ <br />❑ <br />❑ <br />❑ ❑ <br />❑ <br />❑ <br />Dispenser Sump #3&4 <br />X <br />❑ <br />❑ <br />❑ <br />❑ ❑ <br />❑ <br />❑ <br />Dispenser Sump #5&6 <br />X <br />❑ <br />❑ <br />❑ <br />❑ ❑ <br />❑ <br />❑ <br />Dispenser Sump #7&8 <br />X <br />❑ <br />❑ <br />❑ <br />❑ ❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ ❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ ❑ <br />❑ <br />❑ <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: _fol s �t sa Date: April 10, 2013 <br />