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OU 10 2017 <br /> SWRCB,January 2002 Page of <br /> ENVIRONMEN L HEALTH <br /> Secondary Containment Testing Report For A Tf IT <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: Tiwana Gas&Food I Date of Testing: July 31,2017 <br /> Facility Address: 1210 East Hammer Lane, Stockton,Ca.95210 <br /> Facility Contact: Paul Tiwana I Phone: (209)477-3111 <br /> Date Local Agency Was Notified of Testing: 7/27/2017 <br /> Name of Local Agency Inspector(if present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Afford-a-test <br /> Technician Conducting Test: Benjamin F.Duncan Jr./ICC Service Technician#5246802-UT <br /> Credentials: X CSLB Licensed Contractor X SWRCB Licensed Tank Tester <br /> License Type: A License Number:CSLB#341375/SWRCB#90-1120 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> Caldwell Systems Piping Sum s/UDC's 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 ❑ ❑ ❑ UDC #7&8 ❑ X ❑ ❑ <br /> Annular Tank#2 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Annular Tank#3 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Secondary Pipe#1 ❑ X ❑ ❑ ❑ ❑ ❑ ❑ <br /> Secondary Pipe#2 ❑ X ❑ ❑ ❑ ❑ ❑ ❑ <br /> Secondary Pipe #3 ❑ X ❑ ❑ ❑ ❑ ❑ ❑ <br /> Piping Sump#1 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Piping Sump#2 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Piping Sump#3 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> UDC #1&2 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> UDC #3&4 ❑ X ❑ ❑ ❑ ❑ ❑ ❑ <br /> UDC #5&6 ❑ 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: w� Y? �tast a Date: July 31,2017 <br />