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SWRCB, January 2002 <br />Page of <br />Secondary Containment Testing Report For <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 (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: Pacific Car Wash I Date of Testing: May 16, 2013 <br />Facility Address: 4405 Pacific Ave., Stockton, Ca. 95207 <br />Facility Contact: Tammy I Phone: (209) 478-5504 <br />Date Local Agency Was Notified of Testing : 4/17/13 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 <br />License Number: 90-1120/ICC #5246802 -UT <br />Manufacturer Training <br />Manufacturer Component(s) Date Training Expires <br />Not <br />Tested <br />Repairs <br />Made <br />Annular Tank #1&2 <br />X <br />Component <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs Component Pass <br />Made <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />Annular Tank #1&2 <br />X <br />❑ <br />❑ <br />❑ Dispenser Sump #1&2 X <br />❑ <br />❑ <br />❑ <br />Secondary Pipe #1 <br />X <br />❑ <br />❑ <br />❑ Dispenser Sump#3&4 X <br />❑ <br />❑ <br />❑ <br />Secondary Pipe #2 <br />X <br />❑ <br />❑ <br />❑ Dispenser Sump#5&6 X <br />❑ <br />❑ <br />❑ <br />Secondary Pipe #3 <br />X <br />❑ <br />❑ <br />❑ Dispenser Sump #7&8 X <br />❑ <br />❑ <br />❑ <br />Secondary Pipe #4 <br />X <br />❑ <br />❑ <br />❑ Dispenser Sump #9&10 X <br />❑ <br />❑ <br />❑ <br />Secondary Pipe #5 <br />X <br />❑ <br />❑ <br />❑ Dispenser Sump #11&12 X <br />❑ <br />❑ <br />❑ <br />Secondary Pipe #6 <br />X <br />❑ <br />❑ <br />❑ ❑ <br />❑ <br />❑ <br />❑ <br />Secondary Pipe #7 <br />X <br />❑ <br />❑ <br />❑ ❑ <br />❑ <br />❑ <br />❑ <br />Secondary Pipe #8 <br />X <br />❑ <br />❑ <br />❑ ❑ <br />❑ <br />❑ <br />❑ <br />Piping Sump #1 <br />X <br />❑ <br />❑ <br />❑ ❑ <br />❑ <br />❑ <br />❑ <br />Piping Sump #2 <br />X <br />❑ <br />❑ <br />❑ ❑ <br />❑ <br />❑ <br />❑ <br />Transition Sump <br />X <br />❑ <br />❑ <br />❑ ❑ <br />❑ <br />❑ <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: ��af�elJ�� Date: May 16, 2013 <br />