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SWRCB, January 2002 • DECEIVED SEP 4316 o'— Secondary ' Secondary Containment Testing Report Form This form is intended for use by contractors performing periodic testing of UST secondarycoEN"F"?&NiFAh0EALTH appropriate pages of this form to report results for all components tested. The completed form, writte $ Tid printouts from tests (f applicable), should be provided to the facility owner/operator for submittal to t e ocal regulatory agency. 1 _ FACTT,TTV TNFnRMATTnN Facility Name: Flag City Shell Date of Testing: September 14, 2016 Facility Address: 6437 West Banner Street, Lodi, Ca. 95242 Facility Contact: Bill or Rupi I Phone: (209) 914-8735 Date Local Agency Was Notified of Testing: 8/10/2016, by Afford -A -Test Name of Local Agency Inspector (f present during testing): 2. TESTING CONTRACTOR INFORMATION Name: R&D Compliance T 3_ STTMMARV OF TF,ST RFSTTI,TS Component Pass Fail Not Tested Repairs Component Made Pass Fail Not Repairs Tested Made Annular Tank #1 X ❑ ❑ ❑ Dispenser Sump #9&10 X ❑ ❑ ❑ Annular Tank #2&3 X ❑ ❑ ❑ Dispenser Sump # 11 & 12 X ❑ ❑ ❑ Secondary Pipe #1 X ❑ ❑ ❑ Dispenser Sump #13&14 X ❑ ❑ ❑ Secondary Pipe #2 X ❑ ❑ ❑ Dispenser Sump #15&16 X ❑ ❑ ❑ Secondary Pipe #3 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ Piping Sump #1 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ Piping Sump #2 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ Piping Sump #3 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ Dispenser Sump #1&2 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ Dispenser Sump #3&4 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ Dispenser Sump#5&6 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ Dispenser Sump#7&8 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ 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: `i�nelJula Date: September 14, 2016