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REPEIVPD <br /> SWRCB,January 2002 age o <br /> Secondary Containment Testing Report Form JAN 2016 <br /> This form is intended for use by contractors performing periodic testing of UST secondary containment sys '�IENTAL <br /> appropriate pages of thisform to report resultsfor all components tested. The completed form, written t GENT <br /> printoutsfrom tests(ifapplicable), should be provided to thefacility owner/operatorfor submittal to the Iota regu7aiory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Two Guys Valero I Date of Testing: December 16,2015 <br /> Facility Address: 147 East Lathrop Rd.,Lathrop,Ca.95330 <br /> Facility Contact: Greg Cattanach Phone: (209)858-2666 <br /> Date Local Agency Was Notified of Testing: 11/10/2015,by Afford-A-Test <br /> Name of Local Agency Inspector(f present during testing): <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-UC <br /> Manufacturer Training <br /> Manufacturer Component(s)) Date Training Expires <br /> Caldwell Systems Piping Sum s/UDC's July, 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#1-87 X ❑ ❑ ❑ Dispenser Sump 45&6 X ❑ ❑ ❑ <br /> Annular Tank#2-91 X ❑ ❑ ❑ Dispenser Sump#7&8 X ❑ ❑ ❑ <br /> Annular Tank#3-Diesel X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Secondary Pipe#1-87 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Secondary Pipe#2-91 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Secondary Pipe#3-Diesel X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Secondary Pipe 44-Vapor X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Piping Sump#1-87 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Piping Sump#2-91 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Piping Sump#3-Diesel X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Dispenser Sump#1&2 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Dispenser Sump 43&4 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 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: December 16 2015 <br />