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SWRCB;January 2002 0 0 Page of <br /> Secondary Containment Testing Report Form <br /> IRECEIVED <br /> This form is intendedfor use by contractors performing periodic testing of UST secondary containment systeU e e, S <br /> appropriate pages of this form to report results for all components tested. The completed form, written test p d & A <br /> printouts from tests(rf applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> VVIR L <br /> Facility Name: Lodi Pacific Pride Date of Testing: August 26,2011 <br /> Facility Address: 351 North Beckman Rd.,Lodi,Ca.95240 <br /> Facility Contact: Ted Shackelford Phone: (209)649-8308 <br /> Date Local Agency Was Notified of Testing: 7/29/11 by Afford-A-Teat <br /> Name of Local Agency Inspector(if 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 Training <br /> Manufacturer Component(s) Date Training Expires <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> Annular Tank#1 X ❑ ❑ ❑ Secondary Pipe #8 X ❑ ❑ ❑ <br /> Annular Tank#2 X ❑ ❑ ❑ Secondary Pipe#9 X ❑ ❑ ❑ <br /> Annular Tank#3 X ❑ ❑ 1 ❑ Secondary Pipe#10 X 1 ❑ ❑ ❑ <br /> Annular Tank#4 X ❑ ❑ ❑ Secondary Pipe#11 X ❑ ❑ ❑ <br /> Annular Tank#5 X ❑ ❑ ❑ Secondary Pipe#12 X ❑ ❑ ❑ <br /> Secondary Pipe#1 X ❑ ❑ ❑ Piping Sump#1 X ❑ ❑ ❑ <br /> Secondary Pipe#2 X ❑ ❑ ❑ Piping Sump#2 X ❑ ❑ ❑ <br /> Secondary Pipe#3 X ❑ ❑ ❑ Piping Sump#3 X ❑ ❑ ❑ <br /> Secondary Pipe#4 X ❑ ❑ ❑ Piping Sump#4 X U ❑ ❑ <br /> Secondary Pipe#5 X ❑ ❑ ❑ Piping Sump#5 X ❑ ❑ ❑ <br /> Secondary Pipe#6 X ❑ ❑ ❑ Vent Box Sump X ❑ ❑ ❑ <br /> Secondary Pipe#7 X ❑ ❑ I ❑ Dispenser Sump #1&2 X ❑ ❑ ❑ <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 /> 014V - <br /> Technician's Signature: el/ Date: August 26,2011 <br /> a�� L <br />