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• •ECENED <br /> SWRCB,January 2002 MAY 29 2018 Page_of <br /> Secondary Containment Testing Report EINMENTAL <br /> ��....��FF��II TH DEPARTMENT <br /> This form is intended far use by contractors performing periodic testing of UST secondary ffAk nment systems. Use the <br /> appropriate pages of this form to report results for all components tested The completedform, written test procedures, and <br /> printoutsfrom tests(fopplicable), should be provided to thefacility owner/operatorforsubmittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Gemco Ripon Truck Plaza Date of Testing: May 15,2018 <br /> Facility Address: 1022 South Hwy.99 Frontage Rd.,Ripon,Ca.95366 <br /> Facility Contact: Gurpreet Johal Phone: (209)599-5900 <br /> Date Local Agency Was Notified of Testing: 4/10/2018 <br /> Name of Local Agency Inspector(if 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 Lic.#341375/SWRCB Lic.#90-1120 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <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 /> Annular Tank#1&2 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Secondary Pipe #1-87 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Secondary Pipe#2-91 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Piping Sump#1-87 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Piping Sump #2-91 X I ❑ I ❑ ❑ ❑ ❑ ❑ ❑ <br /> Dispenser Sump #1&2 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Dispenser Sump#3&4 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ [1— <br /> E <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ 1 ❑ 1 ❑ ❑ ❑ ❑ ❑ ❑ <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 <br /> iin'this <br /> document are accurate and in full compliance with legal requirements <br /> Technician's Signature: Date: May 15,2018 <br />