Laserfiche WebLink
n <br />SWRCB, January 2002 <br />v <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: Lodi Memorial Hospital I Date of Testing: October 13, 2011 <br />Facility Address: 975 South Fairmont Ave., Lodi, Ca. 95240 <br />Facility Contact: Randy Roehrich I Phone: (209) 339-7667 <br />Date Local Agency Was Notified of Testing : 9/19/2011 by Afford -A -Test <br />Name of Local Agency Inspector (f present during testing): <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: R&D Compliance Testing <br />Technician Conducting Test: Benjamin F. Duncan Jr. <br />Credentials: ❑ CSLB Licensed Contractor X SWRCB Licensed Tank Tester <br />License Type: Tank Tester License Number: 90-1120/ICC#5246802-UT <br />Manufacturer TraininE <br />Manufacturer Component(s) Date Training Expires <br />3. SUMMARY OF TEST RESULTS <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 by, R&D Compliance Testing. <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: Ar fail �fftsa Date: October 13, 2011 <br />Secondary Pipe# I©OOQI <br />000 <br />Secondary Pipe <br />©O00 <br />��00 <br />Piping' ' <br />©O00 <br />000 <br />000', <br />000 <br />�aoo <br />o000 <br />�oo0 <br />0000 <br />�000 <br />a000 <br />�000, <br />a000 <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 by, R&D Compliance Testing. <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: Ar fail �fftsa Date: October 13, 2011 <br />