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11 <br />SWRCB, January 2002 <br />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 (fapplicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />FACTT.TTV INFORMATION <br />Facility Name: Ace Tomato Company, Inc. I Date of Testing: December 15, 2011 <br />Facility Address: 2771 East French Camp Road, French Camp, Ca. 95336 <br />Facility Contact: Mike Edgar I Phone: (209) 982-5691 <br />Date Local Agency Was Notified of Testing: 11/3/2011 by Afford -A -Test <br />Name of Local Agency Inspector (if 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-UT <br />Manufacturer Training <br />Manufacturer Comnonent(s) Date Trainine Expires <br />K ►/' 1/ = : Z�7 SII Y �fJ Illi �W111 SIF` <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: IqLon��Date: December 15, 2011 <br />Annular Tank • <br />Mmm= <br />MMM=Annular <br />', <br />Tank #2 -Unleaded -nmmm <br />Dispenser Sump #I-Diesel_____;nmm <br />Dispenser Sump #2 -Unleaded <br />nmmm <br />mmmm <br />MM=M <br />mom <br />a000 <br />0000; <br />0000 <br />0000 <br />0000 <br />0000 <br />0000, <br />0000 <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: IqLon��Date: December 15, 2011 <br />