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W/O#:1 13d726�75 <br /> SWRCB,January 2002 Page I of 7 <br /> Secondary Containment Testing Report Form <br /> This form is intended for use by contractors performing periodic testing of UST secondary containmentsystems. Use the <br /> appropriate pages of this form to report results far all components tested The completed form,written test procedures,and <br /> printouts from tests(if applicable),should be provided to thefacitity owner/operator for.submittal to the local regulators,agency. <br /> I.FACILITY INFORMATION <br /> Facility Name: LODICA Lodi CA FO Term(Intl) I Date of Testing:9110113 <br /> Facility Address: 2500 West Turner Road Lodi CA <br /> Facility Contact: Masood Choudhurry Phone:909-613-1553 <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Ageriq Inspector Prt sent f jpresenl during testing): <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: SunWest Engineering Constructors,Inc. <br /> Technician Conducting Test: Leonardo Aguilar <br /> Credentials: ®CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester <br /> License Type. General Engineering"A" License Number:703190 <br /> Manufacturer Training <br /> Manufacturer Com wn s Date Training Expires <br /> OWENS CORNING UST NEVER EXPIRES <br /> INCON TS-STS 11/21113 <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Repairs Component pass Fail Not Repairs <br /> Component Pass Fail Tested Made p Tested Made <br /> TURBINE SUMP 1 Q ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> TURBINE SUMP 2 © ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> SPILL BUCKET ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ANNULAR SPACE nX ❑ ❑ 1 ❑ 1 ❑ ❑ ❑ ❑ <br /> SUPPLY LINE I p 01 ❑ 1 ❑ ❑ ❑ 1 ❑ ❑ <br /> SUPPLY LINE 2 X❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> RETURN LINE 0 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> E] 1111E] ❑ El 11 ❑ <br /> 001 ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 001 ❑ ❑ 1 10 ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ JEIJO ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> TR ANSPORTED TO NEXT TESTING FACIT ITY <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,thefads stated In this document are accurate and in full compliance with legal requirements <br /> DA�0 4 Lema*Rg*br W1fl 07N75 <br /> Technician's Signature: anmi Date:9110113 <br /> Revision: <br /> QAIQG APPROVED <br /> 9111120132:41 PMMikeP. B <br />