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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 j <br /> appropriate pages of this form to repor7 results for all components tested. The completed form, written test procedures, and <br /> printouts fi•orn 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: 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 (fpresent during testing) : <br /> I TESTING CONTRACTOR INFORMATION <br /> Company Name: Afford-a-test <br /> Technician Conducting Test: Benjamin F. Duncan Jr. /ICC 95246802-UT <br /> Credentials : X CSLB Licensed Contractor X SWRCB Licensed Tank Tester <br /> License Type: A License Number: CSLB Lie. #341375/SWRCB Lie. #90- 1120 <br /> Manufacturer Trainins <br /> Manufacturer Components Date Training Expires <br /> Caldwell Systems Piping Sum s/UDC ' s July 5 , 2020 <br /> I <br /> 3 . SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component )?ass Fail Not Repairs i <br /> Tested Made Tested Made <br /> Annular Tank # 1 &3 X ❑ ❑ ❑ Dispenser Sump #5 &6 X ❑ ❑ ❑ <br /> Annular Tank. #2 &4 X ❑ ❑ ❑ Dispenser Sump #7&8 X ❑ ❑ ❑ <br /> Secondary Pipe # 1 X ❑ p ❑ Dispenser Sump #9& 10 X 1 ❑ ❑ ❑ <br /> Secondary Pipe #2 X ❑ ❑ ❑ ❑ 0 ❑ 0 <br /> Secondary Pipe #3 X ❑ ❑ 0 ❑ ❑ ❑ 0 <br /> Secondary Pipe #4 X ❑ ❑ ❑ 0 ❑ ❑ 0 <br /> Piping Sump # 1 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Piping Sump #2 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ i <br /> Piping Sump #3 X ❑ ❑ ❑ ❑ ❑ ❑ 0 <br /> Piping Sump #4 X p ❑ ❑ ❑ ❑ ❑ 0 <br /> Dispenser Sump # 1 &2 X ❑ ❑ ❑ ❑ 0 0 0 <br /> Dispenser Sump #3 &4 X ❑ ❑ ❑ ❑ ❑ ❑ 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 /> i <br /> I <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 /> i <br /> I <br /> Technician's Signature: i ruoD,� Date: January 16, 2018 j <br /> I <br /> I <br /> E <br /> I <br />