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WSWRCIB, January 2002 41 REdErVVEX Secondary Containment Testing Report Form This form is intended for use by contractors performing periodic testing of UST secondary containment syste RI W i 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 th 1. FACILITY INFORMATION Facility Name: Miramar Enterprises I Date of Testing: February 28, 2011 Facility Address: 1605 South El Dorado St., Stockton, Ca. 95206 Facility Contact: Angel Balaji I Phone: (209) 939-1906 Date Local Agency Was Notified of Testing: 2/22/2011 by Afford -A -Test Name of Local Agency Inspector (f present during testing): 2. TESTING CONTRACTOR INFORMATION Component Pass Fail Not Tested Repairs Made Component Pass Fail Not Tested Repairs Made Annular Tank # 1 &2 X ❑ ❑ ❑ ❑ ❑ ❑ Secondary Pipe #1 X ❑ ❑ ❑ ❑ ❑ ❑ Secondary Pipe #2 X ❑ ❑ ❑ ❑ ❑ ❑ Piping Sump #1 X ❑ ❑ ❑ ❑ ❑ ❑ Piping Sump #2 X ❑ ❑ ❑ ❑ ❑ ❑ Dispenser Sump #1&2 X ❑ ❑ ❑ ❑ ❑ 1 Dispenser Sump #3&4 X ❑ ❑ ❑ D ❑ ❑ Dispenser Sump # 5&6 X ❑ ❑ D ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ D ❑ 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: onmsrta 9�—�?zx Date: February 28, 2011