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SWRCB, January 2002 Secondary Containment Testing Report Form JUN 12 2014 This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the appropriate pages of this form to report results for all components tested. The completed form,w ' &adW printouts from tests (f applicable), should be provided to the facility owner/operator for submitta o e o orLTHy 1. FACILITY INFORMATION Facility Name: Ace Tomato Company, Inc. I Date of Testing: December 15, 2011 Facility Address: 2771 East French Camp Road, French Camp, Ca. 95336 Facility Contact: Mike Edgar I Phone: (209) 982-5691 Date Local Agency Was Notified of Testing: 11/3/2011 by Afford -A -Test Name of Local Agency Inspector (if present during testing): 2. TESTING CONTRACTOR INFORMATION 3. SUMMARY OF TEST RESULTS Component Pass Fail Not Tested Repairs Made Component Pass Fail Not Tested Repairs Made Annular Tank #1 -Diesel X ❑ ❑ ❑ ❑ ❑ ❑ ❑ Annular Tank #2 -Unleaded X ❑ ❑ ❑ ❑ ❑ ❑ ❑ Dispenser Sump #1 -Diesel X ❑ ❑ ❑ ❑ ❑ ❑ ❑ Dispenser Sump #2 -Unleaded X ❑ ❑ ❑ ❑ ❑ 1 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ 1 ❑ ❑ ❑ ❑ ❑ ❑ ❑ If hydrostatic testing was performed, describe what was done with the water after completion of tests: Test Fluid Supplied and recovered for reuse by, R&D Compliance Testing. 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: nt�� Date: December 15, 2011