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�+ C93 `ehi i SWRCB, January 2002 Page of Secondary Containment Testing Report Form JUL 17 (- 16 This form is intended for use by contractors performing periodic testing of UST secondary containmen RO a,4lw appropriate pages of this form to report results for all components tested. The completed form, writttstrcls,$ printouts from tests (f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. 1. FACILITY INFORMATION Facility Name: San Joaquin County Downtown Garage I Date of Testing: July 11, 2018 Facility Address: 121 South San Joaquin Street, Stockton, Ca. 95202 Facility Contact: Robert West I Phone: (209) 468-2068 Date Local Agency Was Notified of Testing: 6/11/2018 Name of Local Agency Inspector (if present during testing): 2. TESTING CONTRACTOR INFORMATION Name: Afford -a -test 3. SUMMARY OF TEST RESULTS Component Pass Fail Not Tested Repairs Made Component Pass Fail Not Tested Repairs Made Annular Tank #1 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ Secondary Pipe #1 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ Secondary Pipe #2 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ Secondary Pipe #3 X 1 ❑ ❑ 1 ❑ ❑ ❑ 1 ❑ 1 ❑ Secondary Pipe #4 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ Secondary Pipe #5 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ Secondary Pipe #6 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ Piping Sump #1 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ Piping Sump #2 X I ❑ ❑ I ❑ ❑ ❑ ❑ ❑ Piping Sump #3 X ❑ ❑ ❑ ❑ ❑ 1 ❑ ❑ Dispenser Sump #1 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ Dispenser Sump #2 X ❑ ❑ ❑ ❑ L ❑ ❑ ❑ If hydrostatic testing was performed, describe what was done with the water after completion of tests: Test Fluid Supplied and recovered for reuse. CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING To the best of my knowledge, the facts stated in this document are accurate and in full compliance with legal requirements Technician's Signature: Date: July 11, 2018