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r RECEIVED <br /> 5Lp 0 5 2018 %%/0#: 180x08-002 <br /> Secondary Containment Testing I AQ Psi � <br /> � �I�TH f) PARTP� -.N7 <br /> %Iris onn is intended far ttse by cowraciors performing periodic•resting gf11Sl'.tc► r an•cantaitunew sv.genas. 1)se the <br /> appropriate pages of this form to report results for all ctunponerts tested. Tite cwnpleled form, i1•rillen lcs1 procedures, and <br /> printouts from tests(if applic•ahle 1, .ehuuld he prorided to the faciliti,owncr/opertrlor.for stibntittal to the local regulaton,agency. <br /> I. FACILITY INFORMATION <br /> Facilei} Name Lodi CA FO Term(Intl) Date of Tcsting:09!05/18 <br /> Facility Address: 2500 West Turner Road,Lodi,CA 95242 dennis.gritsko@verizon.com <br /> Facility Contact: Dennis Gritsko Phone ] Initial C Repair T��i <br /> Date Local Agency Was Notified of Testing: ] G Month Other <br /> Name of Local Agency Inspector(iI present during testing): ZUNA BARKER —1 Triennial <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name:SLmWest Engineering Const.,Inc. <br /> Technician Conducting Test: Leonardo Aguilar laguilar®sunwestengineering.com <br /> Credentials: O CSLB Liccnsed C'onirictor ❑ SWRCB Licensed I;mk Tester m ICC UST Scn-ice Technician <br /> License Type: TYPE A License Number:103190 <br /> Nlanut•acturer Trainino <br /> �L;nufacturcr Component(s) Date Training Expires <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repair+ Component Pass Fail Not Repair% <br /> Tested Made Tested Made <br /> ANNULAR SPACE ® ❑ ❑ C D D ❑ D <br /> U I u ❑ L u U u u <br /> 0 E ❑ c n ri n n <br /> U u u L u u ❑ u <br /> U u u u u o u u <br /> U u u u u u u u <br /> U u u u u u u u <br /> -- u u u u u u u u <br /> ❑ ❑ ❑ ❑ n n n n <br /> U u u u u u u u <br /> U u u u - u u u u <br /> U u u Li u u u u <br /> If hydrostatic testing was performed,describe what was done with the water after compaction of tests: <br /> For any equipment capable of generating a print out of test results,you must attach a coP). <br /> of the test report to this certification u System printout attached. <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the hest of mr knowledge,the facts slated in this document are accurate and in full compliance with kizal requirement.% <br /> Veonardo 11,1111,sgned by Leonardo <br /> �°rlef 09/05/18 <br /> fectutictatt's Signature: Date:2018.09.05 1522.08Dall'- <br /> r -0roo. <br />