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P 4 <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: SMK Collier Road Chevron Date of Test' J <br /> Facility Address: 25651 North Highway 99,Acampo,Ca. 95220 1 <br /> Facility Contact: Tony Singh Phone: (209)333-1740 JAN 112018 <br /> Date Local Agency Was Notified of Testing: 5/4/2017,by Afford-A-Test <br /> Name of Local Agency Inspector(ifpresent during testing): � NAl- �E <br /> ART T <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: R&D Compliance Testing <br /> Technician Conducting Test: Benjamin F.Duncan Jr. <br /> Credentials: ❑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 /> Caldwell Systems Piping Sumps/UDC's/Fill Riser Sumps July 30, 2017 <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 ❑ ❑ ❑ Dispenser Sump #7&8 X ❑ I ❑ ❑ <br /> Annular Tank#2 X ❑ ❑ ❑ Dispenser Sump #9&10 X ❑ ❑ ❑ <br /> Annular Tank#3 X ❑ ❑ ❑ Dispenser Sump #11&12 X ❑ ❑ ❑ <br /> Secondary Pipe #1 X ❑ ❑ ❑ Fill Riser Sump #1 X ❑ ❑ ❑ <br /> Secondary Pipe #2 X ❑ ❑ ❑ Fill Riser Sump 42 X ❑ ❑ ❑ <br /> Secondary Pipe #3 X ❑ ❑ ❑ Fill Riser Sump#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 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Dispenser Sump#5&6 X ❑ ❑ ❑ ❑ I ❑ ❑ ❑ <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: / � Date: June 19,2017 <br />