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E <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: Two Guys Valero I Date of Testing: December 18, 2012 <br />Facility Address: 147 East Lathrop Rd., Lathrop, Ca. 95330 <br />Facility Contact: Greg Cattanach I Phone: (209) 858-2666 <br />Date Local Agency Was Notified of Testing: 12/4/2012, 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: il 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 />3. SUMMARY OF TEST RESULTS <br />Component <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs Component <br />Made <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />Annular Tank #1-87 <br />X <br />❑ <br />❑ <br />❑ Dispenser Sump #5&6 <br />X <br />❑ <br />❑ <br />❑ <br />Annular Tank #2-91 <br />X <br />❑ <br />❑ <br />❑ Dispenser Sump #7&8 <br />X <br />❑ <br />❑ <br />❑ <br />Annular Tank #3 -Diesel <br />X <br />❑ <br />❑ <br />I ❑ <br />❑ <br />❑ <br />1 ❑ <br />1 ❑ <br />Secondary Pipe # 1-87 <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Secondary Pipe #2-91 <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Secondary Pipe #3 -Diesel <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Secondary Pipe #4 -Vapor <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Piping Sump #1-87 <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Piping Sump #2-91 <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Piping Sump #3 -Diesel <br />X <br />❑ <br />❑ <br />❑ <br />❑❑ <br />❑ <br />11Dispenser <br />Sump #1&2 <br />X <br />El <br />El <br />❑ <br />❑ <br />❑ <br />❑ <br />Dispenser Sump #3&4 <br />X <br />[1❑ <br />❑ <br />❑ <br />El❑ <br />❑ <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: a ml Date: December 18, 2012 <br />