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SWRCB,January 2002 P49e 44�f� — Secondary Containment Testing Report Form This form is intended for use by contractors performing periodic testing of UST secondary containme sj hs )ns.-Me the i appropriate pages of this form to report results for all components tested. The completed form, written test prdcedu artd printouts from tests(f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. 1. FACILITY INFORMATION Facility Name: Sinclair/Gaslo I Date of Testing: May 4,2017 Facility Address: 7906 North El Dorado Street,Stockton,Ca.95210 Facility Contact: Paul Trehan or Manan I Phone: (209)957-2987 Date Local Agency Was Notified of Testing: 5/3/2017,by Afford-a-test,Ok per Garrett Backus,REHS 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 Traininii Manufacturer Component(s) Date Training Expires Caldwell Systems UDC July 30, 2017 3. SUMMARY OF TEST RESULTS Component Pass Fail Not Repairs Component Pass Fail Not Repairs Tested Made Tested Made Secondary Pipe 44-Super 91 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ Dispenser Sump#1&2 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ 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: yamr,� �� Date: May 4,2017