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Page 1 of 9 ecq� <br /> Secondary Containment Testing Report Form <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,fi•om tests(if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Bonfare Market#35 1 Date of Testing: 04/12/2016 <br /> Facility Address: 15 E. Grantline Road, Tracy, CA 95376 <br /> Facility Contact: Ali Amid I Phone: (925) 331-7403 <br /> Date Local Agency Was Notified of Testing : 04/06/2016 <br /> Name of Local Agency Inspector(if present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: ECO-CHEK Compliance, Inc. <br /> Technician Conducting Test: Nik Zagorov <br /> Credentials: ® CSLB Licensed Contractor ® SWRCB Licensed Tank Tester <br /> License Type: A License Number: 958763 <br /> Manufacturer Training <br /> Manufacturer Com onent(s) Date Training Expires <br /> Caldwell Instruments, Inc. Level Change Indicator 12/01/2016 <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> (3)Annular Space ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 7 Secondary Pipe Run ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 4 Secondary Pipe Sump ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 3 UDC ® I ❑ ❑ 1 ❑ ❑ ❑ I ❑ ❑ <br /> 3 Secondary Fill SumpI ❑ ❑ I ❑ ❑ ❑ I ❑ ❑ <br /> ❑ I ❑ ❑ 1 ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ I ❑ ❑ ❑ I ❑ ❑ ❑ ❑ <br /> El El Ll° ❑ El El°❑ ❑❑ o <br /> ❑ ❑ ❑ 1 ❑ 11 ❑LEI ❑ I ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> Placed in a 330 gallon tank on a trailer and hauled for reuse as test water Cdr <br /> A <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: Date: 04/12/2016 <br /> APR 2 5 2016 <br /> w <br />