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, 4 <br />'1ECElVED <br />SWRCB, January 2002 Page of <br />25 <br />Secondary Containment Testing Report Form EP 2018 <br />This form is intended for use by contractors performing periodic testing of LIST secondarAPE <br />' r sf-(LwgTH <br />appropriate pages of this form to report results for all components tested. The completed orm, wrr an <br />printouts from tests (if applicable), should be provided to the facility owner/operator for submittal t ry agency. <br />1. FACILITY INFORMATION <br />Revised <br />Facility Name: City of Lodi/Lodi Corporation Yard Date of Testing: March 29, 2018 <br />Facility Address: 1331 South Ham Lane, Lodi, Ca. 95241 <br />Facility Contact: Randy Laney I Phone: (209) 333-6830 <br />Date Local Agency Was Notified of Testing: 3/26/2018 <br />Name of Local Agency Inspector (rfpresent during testing): Zuna Barker, EHS <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: Afford -a -test <br />Technician Conducting Test: <br />Benjamin F. Duncan Jr. /ICC #5246802 -UT <br />Credentials: X CSLB Licensed Contractor X SWRC13 Licensed Tank Tester <br />License Type: A <br />Component <br />License Number: CSLB Lic. #341375/SWRCB Lic. #90-1120 <br />Manufacturer <br />Manufacturer Training <br />Component(s) Date Training Expires <br />Caldwell Systems <br />Piping Sum s/ JDC July 5, 2020 <br />Veeder Root <br />Startup & Service Tech (Level 4) Tech #A23152 July 5, 2019 <br />❑ <br />❑ <br />❑ <br />3. SUMMARY OF TEST RESULTS <br />Component <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />Component <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />Secondary Pipe #3 <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Piping Sump #2 <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Dispenser Sump #1&2 <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <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 />Note: Verified functionality of UDC Sensor to comply with Repair Permit conditions. <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: �y�i Date: March 29, 2018 <br />v <br />