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Secondary Containment Testing Report Form <br /> This foriu is intended,/or use by contraclors petf rrimin inxioc/ic testing of UST secondary containmew s*nsten a. (Ave the <br /> alywopriate pages of this foi7n io repart results for all carnponeuts tested. The cornlileted foriu, written test prac•edures,and <br /> printouts frau tests(if applicable),should be provided to the facilih•owner/operator for submittal to the local regulalory agenc v. <br /> i. FACILITY INFORMATION <br /> Facility Name: Lodi CA FO Term(Intl) Date of Testing: 09/05/1a <br /> Facility Address: 2500 West Turner Road, Lodi,CA 95242 dennis.gritsko@verizon.com <br /> Facility Contact: Dennis Gritsko Pllone :1 initial C Repair Test <br /> Date Local Agency Was Notified of Testing: :16 Motith IL Other <br /> Name of Local Agency Inspector(ifpresenl during lestingd: ZONA BARKER —1 Triennial <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name:SunWest Engineering Const.,Inc. <br /> Technician Conducting Tcsc Leonardo Aguilar laguilar@sunwestengineering.com <br /> Credentials: ❑CSLB Licensed Contractor ❑ SWRCB Licensed Tmik Tester ® ICC UST Service Technician <br /> Licenw Type: TYPE License Number;703190 <br /> Manufacturer Training,- <br /> Manufacturer Component(s) Date Training Expire <br /> lEp 14 ZM <br /> 3. SUMMARY OF TEST RESULTS WAFNTAL <br /> Not Repairs ",4 hairs <br /> T <br /> Componcut 11ass Fait Component � k <br /> e+ted Made Tested Made <br /> ANNULAR SPACE © U U L ❑ ❑ ❑ ❑ <br /> U U U L U U Ll L <br /> ❑ ❑ ❑ c n ❑ n n <br /> U U u L u U u u <br /> CJ U U 1-i <br /> U U U U LJ Ll U Ll <br /> U U U U U U U U <br /> ❑ U U U - - LI U U unc <br /> _._�.. _._- . _.____.. ❑ ❑ ❑ ❑_ n _ _- <br /> n <br /> _ U U U u ._ _ U U u <br /> U U U u U u U u <br /> Li u u u ILL u u u <br /> if hydrostatic testing was perfonned,describe what v;as done with the water after completion of tests: <br /> For any equipment capable of generating a print out of test results,you must attach a copy <br /> of the test report to this certification U System printout attached. <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of nht,knosrlet/.e,the.itcts stated in this document are accurate and in fitll compliance with legal regtrirenrents <br /> rgulilar <br /> oardo Digitally signed by Leonardo <br /> nate:2 tale: 09/05/18 <br /> Technician's Signature: Dace:zo,s.aa.as 15:22:03 <br /> -07,00, <br /> QA/QC APPROVED <br /> 9/5/20183:43 PMTeresa Ant <br />