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IV <br /> SWRCB , January 2002 JAN 0 2 PW 9 of <br /> Secondary Containment Testing Report Form. <br /> This form is intended for use by contractors performing periodic testing of UST secondary containmehtf systi3M& Usge the, l 77 <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 : Gas Depot Date of Testing : January 23 , 2018 <br /> Facility Address : 1330 East Yosemite Ave . , Manteca, Ca. 95336 <br /> Facility Contact: Kevin I Phone : (209) 825 -0332 <br /> Date Local Agency Was Notified of Testing : 12/ 11 /2017 <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 . #904120 <br /> r _ _ � <br /> Manufacturer Training <br /> Manufacturer Com onerit(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 I Tested Made <br /> Annular Tank # 1 X ❑ ❑ ❑ Dispenser Sump #9 & 10 X ❑ ❑ ❑ <br /> Annular Tank #2 & 3 X ❑ ❑ ❑ Dispenser Sump # 11 & 12 X ❑ ❑ ❑ <br /> Secondary Pipe # 1 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Secondary Pipe #2 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Secondary Pipe #3 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Piping Sump # 1 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Piping Sump #2 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Piping Sump #3 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Dispenser Sump # 1 &2 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Dispenser Sump #3 &4 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Dispenser Sump #5 &6 X ❑ ❑ ❑ ❑ ❑L ❑ ❑ <br /> Dispenser Sump #7 & 8 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 : Yeww rov Date : January 23 , 2018 <br />