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SWRCB,January 2002 Page of <br /> Secondary Containment Testing Report Form <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(f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: DKS Investments/West Lane Chevron I Date of Testing: June 29,2018 <br /> Facility Address: 9484 West Lane,Stockton,Ca.95210 <br /> Facility Contact: Jerry of Tanknology Phone: (209)329-8374 <br /> Date Local Agency Was Notified of Testing: 6/20/2018,by Afford-A-Test <br /> Name of Local Agency Inspector(if present during testing): i <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Afford-a-test <br /> Technician Conducting Test: Benjamin F.Duncan Jr./ICC#5246802-UT <br /> Credentials: X CSLB Licensed Contractor X SWRCB Licensed Tank Tester <br /> License Type: A License Number: CSLB Lic. #341375/SWRCB Lic.490-1120 <br /> Manufacturer TraininE <br /> Manufacturer Component(s) Date Training Ex ices <br /> Caldwell Systems Piping Sum s/UDC's July 5, 2020 <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> Secondary Pipe #1-87 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Secondary Pipe #2-91 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Secondary Pipe #3-Diesel X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Piping Sump#1-87 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Piping Sump#2-91 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Piping Sump#3-Diesel X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Dispenser Sump#1&2 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Dispenser Sump#3&4 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Dispenser Sump#5&6 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Dispenser Sump#7&8 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Dispenser Sump#9&10 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Dispenser Sump#11&12 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <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. <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: Wej eo �� Date: June 29,2018 <br />