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0 <br /> SWRCB,January 2002 Page of <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 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: Grewal's Gas&Liquor I Date of Testing: December 5,2011 <br /> Facility Address: 4100 East Freemont St., Stockton,Ca.95215 <br /> Facility Contact: Rick Grewal I Phone: (209)463-5294 <br /> Date Local Agency Was Notified of Testing: 11/2/11 by Afford-A-Test <br /> Name of Local Agency Inspector(fpresent during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Co=Name: &D Compliance Testing <br /> Tet: Benjamin F.Duncan Jr. <br /> CrLicensed Contractor X SWRCB Licensed Tank Tester <br /> LiTank Tester License Number: 90 <br /> Manufacturer <br /> #5246802-UT <br /> Manufacturer Trainine <br /> Manufacturer Component(s) Date Training Expires <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 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Annular Tank#2&3 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Secondary Pipe #1 X ❑ ❑ ❑ ❑ ❑ ❑ 1 ❑ <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 /> Dispenser Sump#1&2 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Dispenser Sump#3&4 rXE1 <br /> El ❑ ❑ ❑ ❑ <br /> Dispenser Sump#5&6 El ❑ ❑ ❑ ❑ ❑ <br /> Dispenser Sump#7&8 ❑ ❑ ❑ ❑ ❑ ❑ <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 by, R&D Compliance Testing. <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: ►vfiaw� �i+ v Date: December 5.2011 <br />