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�17 <br />,WRCB, January 2002of <br />r <br />Secondary Containment Testing Report Form <br />This form is intended for use by contractors performing periodic testing of UST secondary containment systems. LWel 6 2011 <br />appropriate pages ofthis form to report results for all components tested The completed form, written test procedures, and <br />printouts from tests (ifapplicable), should be provided to the facility ownerloperatorfor submittal to the locu W'"49g.4,geocy. <br />, VI <br />1. FACILITY INFORMATION PER,1,V17/,3r--,, LTFi <br />F"CES <br />Facility Name: Parkwood Gas and Food ------FI—Date of Testing: July 27, 2011 <br />Facility Address: 1612 West Hammer Lane, Stockton, Ca. 95209 <br />Facility Contact: Kulwant I hone: (209) 931-3549 (209) 482-2580 <br />Date Local Agency Was Notified of Testing: 7/26/11 by Afford -A -Test <br />Name of Local Agency Inspector (ii(present during testing): Garrett Backus, RENS <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: R&D Compliance Testing <br />Technician Conducting Test: Benjamin F. Duncan Jr. <br />Credentials: 0 CSLB Licensed Contractor X SWRCB Licensed Tank Tester <br />License Type: Tank Tester License Number: 90-1120/ICC #5246802 -UT <br />Manufacturer Training <br />Manufacturer Component(s) Date Training Expires <br />3. SUMMARY OF TEST RESULTS <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <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 will: legal requirements <br />Technician's Signature: ffmyizs 11q—ffWWW81—JT- Date: July 27, 2011 <br />V <br />a)c, <br />Secondary Pipe #1DO��i <br />o000 <br />Secondary Pipe # <br />000=2 <br />Secondary hpe <br />©O��!#3 <br />oo=Oj <br />MW== <br />MMM= <br />M=="§ <br />MM= <br />NM== <br />0000 <br />mom <br />�000 <br />000© <br />o�oo <br />.. <br />o0 <br />0000 <br />=M=M <br />000�' <br />MM=M <br />__ <br />�000 <br />oa�o <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <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 will: legal requirements <br />Technician's Signature: ffmyizs 11q—ffWWW81—JT- Date: July 27, 2011 <br />V <br />a)c, <br />