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OCT-25-2007 17:52 CIT`( OF LODI 209 333 6710 P.04 'Sw�ct;rs, .lanuwy LUU2 Page of Secondary Containment Testing Report Form This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the appropriate pages of this form to report results for all components tested The completed form, written test procedures, and printouts from tests(f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. 1. FACILITY INFORMATION Facility Name: City of Lodi Daze of Testing: 10/5/07 Facility Address: 1331 S.Ham Lane,Lodi Ca Facility Contact_ Dennis Callahan Phone: 20-333-6800 x2690 Date Local Agency Was Notified of Testing: Name of Local Agency Inspector(f present during testing): 2. TESTING CONTRACTOR INFORMATION Company Name: JP Petroleum Service Technician Conducting Test: Gabe Garcia Credentials: x CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester License Type: A License Number: 811471 Manufacturer Trainine Manufacturer Corsa nen s Date Training Expires 3. SUMMARY OF TEST RESULTS Component Pass Fail Not Repairs Component Pass Fail Not Repairs Tested Made Tested Made Line 1 Diesel x ❑ ❑ ❑ ❑ C ❑ ❑', Sump 1 Diesel x ❑ ❑ ❑ p ❑ ❑ ❑ ❑ ❑ 1 ❑ ❑ ❑ 2 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑I ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑, ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ Q o a n El El 0 El ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑' o ❑ ❑ ❑ ❑ ❑ ❑ If hydrostatic testing was performed,describe what was done with the water after completion of tests: Water was filtered and returned to holding tank. CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING To the best of my knowledge, thefacts stated in this oc ment are accurate and in full compliance with legal requirements litf� Date: ` 7 Technician's Signature: _ _