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SWRCB, January 2002 ae of <br /> Secondary Containment Testing Rep hJ�,QrM, <br /> This farm is intended for ttse by contractors performing periodic testing of UST secondary contcfi ,)hent sysidnis W ejh f j <br /> appropriate pages of this form to report results for all components tested. The completed form, Written proceddn es, ands <br /> printouts from tests (f applicable), should be provided to the facility owne/operator for submittal to the local regulatory agency. <br /> 1 . FACILITY INFORMATION <br /> Facility Name : Tokay Kwik Sery Date of Testing: January 16, 2018 <br /> Facility Address: 420 West Kettleman Lane, Lodi, Ca, 95240 <br /> Facility Contact: Mike or Jas Singh Phone: (209) 369-2790 <br /> Date Local Agency Was Notified of Testing : 12/11 /2017 <br /> Name of Local Agency Inspector (i(present during testing) : <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 Lie, 0341375/SWRCB Lie. #90- 1120 <br /> Manufacturer Training <br /> Manufacturer Com onent(s) Date Training Expires <br /> Caldwell Systems Piping Sum s/UDC ' s July 5 , 2020 <br /> i <br /> i <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs i <br /> Tested Made Tested Made <br /> Annular Tants # 1 &3 X ❑ ❑ ❑ Dispenser Sump #5 &6 X ❑ ❑ ❑ <br /> Annular Tants #2&4 X ❑ ❑ ❑ Dispenser Sump #7&8 X ❑ ❑ ❑ <br /> Secondary Pipe # 1 X ❑ ❑ ❑ Dispenser Sump #9& 10 X ❑ ❑ ❑ <br /> Secondary Pipe #2 X ❑ ❑ D ❑ ❑ 0 0 <br /> Secondary Pipe #3 X El 11 0 0 ❑ ❑ <br /> Secondary Pipe #4 X ❑ ❑ ❑ 0 ❑ ❑ ❑ <br /> Piping Sump # 1 X ❑ ❑ ❑ ❑ ❑ ❑ 0 <br /> Piping Sump #2 X ❑ ❑ 0 0 0 0 <br /> Piping Sump #3 X ❑ ❑ 0 0 0 0 <br /> Piping Sump #4 X ❑ ❑ ❑ 0 0 0 0 <br /> Dispenser Sump # 1 &2 X ❑ EE <br /> 110 0 ❑ ❑ <br /> Dispenser Sump #3 &4 X ❑ 0 ❑ 0 0 0 <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 /> t <br /> I <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To lite best of my knowledge, the facts stated in this document are accurate and lit full compliance with legal reguirentents <br /> Technician's Signature: Date. January 16, 2018 <br /> i <br />