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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: Ace Tomato Company, Inc. I Date of Testing: February 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 (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: ❑ 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 Component(s) Date Training Expires <br />3Yllu <br />l►YAR x'L-OF' Tl f.`11 <br />,]] S]JILT <br />' Annular Tank # I -Diesel <br />Annular Tank •.�p <br />��001 <br />Dispenser • <br />©D00 <br />��OOIDispenser <br />Sump #2 -Unleaded <br />O <br />D000 <br />000 <br />DOOOi <br />000 <br />000! <br />O�OOI�, <br />D000 <br />O�QO,i, <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: ✓fyalm� �7 ��� Date: December 15, 2011 <br />