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SWRCB, January 2002 <br />Page of <br />Secondary Containment Testing Report Form <br />This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the <br />appropriate pages of this form to report results for all components tested. The completed form, written test procedures, and <br />printouts from tests (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: City of Lodi/Lodi Corporation Yard I Date of Testing: October 24, 2017 <br />Facility Address: 1331 South Ham Lane, Lodi, Ca. 95241 <br />Facility Contact: Randy Laney Phone: (209) 333-6830 <br />Date Local Agency Was Notified of Testing: 9/12/2017 <br />Name of Local Agency Inspector (ifpresent during testing): <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: Afford -a -test <br />Pass <br />Technician Conducting Test: Benjamin F. Duncan Jr. /ICC #5246802 -ITT <br />Credentials: X CSLB Licensed Contractor <br />X SWRCB Licensed Tank Tester <br />License Type: A <br />License Number: CSLB Lic. #341375/SWRC13 Lic. #90-1120 <br />Manufacturer <br />Manufacturer Training <br />Component(s) Date Training Expires <br />Caldwell Systems <br />Piping Sumps/UDC July 5, 2020 <br />[I <br />❑ <br />❑ <br />0 <br />0 <br />❑ <br />3. SUMMARY OF TEST RESULTS <br />Component <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />Component Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />Annular Tank #1 <br />X <br />[I <br />❑ <br />❑ <br />0 <br />0 <br />❑ <br />0 <br />Annular Tank #2 <br />X <br />❑ <br />❑ <br />❑ <br />C <br />0 <br />❑ <br />❑ <br />Annular Tank #3 <br />X <br />❑ <br />L] <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Secondary Pipe #1 <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />0 <br />Secondary Pipe #2 <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Secondary Pipe #3 <br />❑ <br />X <br />❑ <br />❑ <br />❑ 1 <br />❑ <br />1 ❑ <br />❑ <br />Piping Sump #1 <br />X <br />❑ <br />❑ <br />0 <br />❑ <br />❑ <br />❑ <br />❑ <br />Piping Sump #2 <br />❑ <br />1 X <br />0 <br />❑ <br />❑ <br />0 <br />❑ <br />❑ <br />Piping Sump #3 <br />X <br />❑ <br />❑ <br />C <br />❑ <br />❑ <br />❑ <br />❑ <br />Dispenser Sump # 1 &2 <br />0 <br />❑ <br />X <br />❑ <br />0 <br />❑ <br />0 <br />❑ <br />❑ <br />❑ <br />0 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />0 <br />❑ <br />❑ <br />❑ <br />0 <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: J`. ��tarrn Date: October 24, 2017 <br />