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APR j 4 2008 EN'VIPO-I�„DENT HEALTKge of SWRCB,January 2002 PER M117/SAVICES Secondary Containment Testing Report Form This form is intended for use by contractors performingperiodic 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(if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. 1. FACILITY INFORMATION Facility Name: Lodi Food&Liquor I Date of Testing: 1/16/08 Facility Address: 1225 W.Locld'ord Lane Lodi,CA 95240 Facility Contact: Paul I Phone: 209-333-1038 Date Local Agency Was Notified of Testing: 1/2/08 Name of Local Agency Inspector(fpresent during testing): 2. TES'TIN'G CONTRACTOR INFORMXri0N Company Name: B.Z.Service Station Maintenance Technician Conducting Test: James Norby Credentials: X CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester License Type: ICC 5246892-UT License Number: 433159 :::.. ... Manufacturer Training Manufacturer Component(s) Date Training Expires 3. SUMMARY OF TEST RESULTS Component Pass Fail Not Repairs Component Pass Fail Not Repairs Tested Made Tested Made 87 STP Sump X ❑ ❑ ❑ 91 Secondary Piping X 0 0 ❑ 0 0 ❑ ❑ 0 0 ❑ ❑ 91 STP Sump X 1 0 0 1 0 Diesel Secondary Piping X 0 ❑ 0 ❑ ❑ 0 ❑ ❑ ❑ ❑ ❑ DSL STP Sump X ❑ 0 ❑ UDC# 1 &2 X ❑ ❑ ❑ ❑ ❑ _❑ 0 _ _ _ ❑ ❑_ . ❑ 87 Annular X ❑ ❑ 0 UDC#3 & 4 X ❑ 0 0 0 ❑ 0 ❑ 0 ❑ ❑ ❑ 91 &Diesel Annular X ❑ ❑ ❑ UDC#5 &6 X ❑ ❑ ❑ ❑ ❑ ❑ 0 0 0 ❑ ❑ 87 Secondary Piping X ❑ ❑ ❑ UDC# 7 & 8 X ❑ ❑ ❑ 0 L—01= 0 ❑ 0 ❑ ❑ If hydrostatic testing was performed,describe what was done with the water after completion of tests: CERTIFICATION OF TECBNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING To the best of my know e,t:e facts st d in this document are accurate and in full compliance with legal requirements Technician's Sign -- Date-.-1/16/08