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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 (af applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: Flag City Shell I Date of Testing: 9/25/2013 <br />Facility Address: 6437 West Banner Street, Lodi, Ca. 95242 <br />Facility Contact: Bill or Rupi I Phone: (209) 914-8735 <br />Date Local Agency Was Notified of Testing: 8/26/2013, 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 />3. SUMMARY OF TEST RESULTS <br />Component <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />Component <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />Annular Tank #1 <br />X <br />❑ <br />❑ <br />❑ <br />Dispenser Sump #9&10 <br />X <br />❑ <br />❑ <br />❑ <br />Annular Tank #2&3 <br />X <br />❑ <br />❑ <br />❑ <br />Dispenser Sump #11&12 <br />X <br />❑ <br />❑ <br />❑ <br />Secondary Pipe #1 <br />X <br />❑ <br />❑ <br />❑ <br />Dispenser Sump 413&14 <br />X <br />❑ <br />❑ <br />❑ <br />Secondary Pipe #2 <br />X <br />❑ <br />❑ <br />❑ <br />Dispenser Sump #15&16 <br />X <br />❑ <br />❑ <br />❑ <br />Secondary Pipe 43 <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Piping Sump #1 <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Piping Sump #2 <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Piping Sump #3 <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Dispenser Sump #1&2 <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Dispenser Sump #3&4 <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Dispenser Sump45&6 <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Dispenser Sump47&8 <br />X <br />El <br />El <br />Ll <br />❑ <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: amu' m��Date: September 25, 2013 <br />