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i , AUG 2 2 2016 SWRCB, January 2002 of Secondary Containment Testing Report Form This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the 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 the local regulatory agency. I FACII.ITV INFORMATION Facility Name: Pacific Car Wash Date of Testing: May 12, 2016 Facility Address: 4405 Pacific Ave., Stockton, Ca. 95207 Facility Contact: Tammy I Phone: (209) 478-5504 Date Local Agency Was Notified of Testing: 4/20/2016, by Afford -A -Test Name of Local Agency Inspector (if present during testing): 2. TESTING CONTRACTOR INFORMATION Company Name: R&D Compliance Testing Technician Conducting Test: Benjamin F. Duncan Jr. Credentials: ❑ CSLB Licensed Contractor X SWRCB Licensed Tank Tester License Type: Tank Tester License Number: 90-1120/ICC #5246802 -UT ammmm Manufacturer Training Manufacturer Component(s) Date Training Expires Caldwell Systems Pining Sumns/Transition Pining Sump/UDC's July 31, 2017 3_ CITMMARV OF TF,ST RFNITI.TS Component Pass Fail Not Tested Repairs Made Component Pass Fail Not Tested Repairs Made Annular Tank # 1 &2 X ❑ ❑ ❑ Dispenser Sump # 1 &2 X ❑ ❑ ❑ Secondary Pipe #1 X ❑ ❑ ❑ Dispenser Sump#3&4 X ❑ ❑ ❑ Secondary Pipe #2 X ❑ ❑ ❑ Dispenser Sump#5&6 X ❑ ❑ ❑ Secondary Pipe #3 X ❑ ❑ ❑ Dispenser Sump #7&8 X ❑ ❑ ❑ Secondary Pipe #4 X ❑ ❑ ❑ Dispenser Sump #9&10 X ❑ ❑ ❑ Secondary Pipe #5 X ❑ ❑ ❑ Dispenser Sump #11&12 X ❑ ❑ ❑ Secondary Pipe #6 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ Secondary Pipe #7 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ Secondary Pipe #8 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ Piping Sump #1 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ Piping Sump #2 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ Transition Sump 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: �m�n� Date: May 12, 2016