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S W RCB,January 2002 Page_of Secondary Containment Testing Report Form This form is intended far use by contractors performing periodic testing of USTsecondmy containment systems. Use the appropriate pages ofthis form to report results for all components tested. The completedform, written test procedures, and printouts from tests(1fapplicable), should be provided to the facilityowner/operator for submittal to the local regulatory agency. 1. FACILITY INFORMATION Facility Name: Tulare Farms,LLLP I Date ofTesting: December 11,2017 Facility Address: 2771 East French Camp Road,French Camp,Ca.95336 Facility Contact: Mike Edgar I Phone: (209)275-8555 Date Local Agency Was Notified of Testing: 11/14/2017 Name of Local Agency Inspector(ef present during testing): 2. TESTING CONTRACTOR INFORMATION Company Name: Afford-a-test Technician Conducting Test: Benjamin F.Duncan Jr./ICC#5246802-UT Credentials: X CSLB Licensed Contractor X SWRCB Licensed Tank Tester License Type: A License Number. CSLB Lic. #341375/SWRCB Lic.#90-1120 M1lanufacturer Trainine Manufacturer Com nent s Date Training Expires Caldwell Systems UDC's July 5, 2020 3. SUMMARY OF TEST RESULTS Component Pass Fail No[ Repaim Component Pass Fail Not Repairs Tested Made Tented Made Annular Tank#]-Diesel X ❑ JEID ❑ ❑ ❑ ❑ Annular Tank 42-Unleaded X ❑ ❑ ❑ ❑ ❑ Dispenser Sump#1-Diesel X ❑ ❑ ❑ ❑ ❑ Dispenser Sump#2-Unleaded X ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑❑ ❑ ❑ ❑ ❑ ❑❑ ❑ LJ ❑ ❑ ❑ If hydrostatic testing was performed,describe what was done with the water after completion of tests: Test Fluid Supplied and recovered for reuse. CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING To the best ofmy knowledge,the facts stated in this document are accurate and in full compliance with legal requirements Technician's Signature: szv� '5vff .� Date: December 11.2017