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SWRCB, January 2002 E-.-.-.CE.IVED N99# klWb— Secondary Containment Testing Report Form ENVIRONMENTAL This form is intended for use by contractors performing periodic testing of UST secondary containment s} s eMq ,7--4T vENT appropriate pages of this form to report results for all components tested. The completed form, written test procedures, and printouts from tests (tf applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. 1. FACILITY INFORMATION Facility Name: El Dorado Food Mart Date of Testing: September 27, 2016 Facility Address: 2320 North El Dorado St., Stockton, Ca. 95204 Facility Contact: Bob & Kathy Lutz -Owners or Kelli-Manager I Phone: (209) 943-1311 Date Local Agency Was Notified of Testing: 8/10/2016, by Afford -A -Test Name of Local Agency Inspector (if present during testing): 2. TESTING CONTRACTOR INFORMATION Company Name: R&D Compliance Testing Technician Conducting Test: Benjamin F. Duncan Jr. Credentials: ❑ CSLB Licensed Contractor X SWRCB Licensed Tank Tester License Type: Tank Tester License Number: 90-1120/ICC #5246802 -UT Manufacturer Training Manufacturer Component(s) Date Training Expires Caldwell Systems Piping Sum s/UDC's July 30, 2017 3. SUMMARY OF TEST RESULTS Component Pass Fail Not Tested Repairs Made Component Pass Fail Not Tested Repairs Made Secondary Pipe #1 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ Secondary Pipe #2 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ Secondary Pipe #3 X 1 ❑ ❑ ❑ I ❑ ❑ ❑ ❑ Piping Sump #1 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ Piping Sump #2 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ Piping Sump #3 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ Dispenser Sump # 1 &3 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ Dispenser Sump #2&4 X ❑ ❑ ❑ ❑ ❑ ❑ 1 ❑ Dispenser Sump #5&7 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ Dispenser Sump #6&8 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ I ❑ I ❑ ❑ ❑ ❑ ❑ 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: MV$4w 91—f Date: September 27, 2016