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SWRCB, January 2002 Page of Secondary Containment Testing Report Form 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, written test procedures, and printouts from tests (f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. 1. FACT ITV INFORMATION Facility Name: Ace Tomato Company, Inc. 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 (f present during testing): 2. TESTING CONTRACTOR INFORMATION Company Name: R&D Compliance Testing Technician Conducting Test: Benjamin F. Duncan Jr. Credentials: ❑ CSLB Licensed Contractor X SWRCB Licensed Tank Tester License Type: Tank Tester License Number: 90-1120/ICC#5246802-UT Manufacturer Manufacturer Training KAWHIEVA 1/ 1.11,41all Date Component Pass Fail Not Tested Repairs Component Made 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 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ El ElEl El El 11 El❑ ❑ 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:. ,Vw seow �` ffa0WM.8,:5;A Date: December 15, 2011