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61 <br />SWRCB, January 2002 <br />F at of <br />Secondary Containment Testing Report Form <br />Thisform is intendedfor use by contractors performing periodic testing of UST secondarycoE%ment 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 Pacific Pride I Date of Testing: August 23, 2017 <br />Facility Address: 351 North Beckman Rd., Lodi, Ca. 95240 <br />Facility Contact: Ted Shackelford I Phone: (209) 649-8308 <br />Date Local Agency Was Notified of Testing: 7/11/2017 <br />Name of Local Agency Inspector (fpresent during testing): <br />a� n1wM10irwKeLoYY!T.TmI[Il Ai.1orI A1174N1810 <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 SWRCB Licensed Tank Tester <br />License Type: <br />A <br />License Number: CSLB Lic.# 34137590/SWRCB 11-20 <br />Manufacturer <br />Manufacturer Trainine <br />Component(s) Date Training Expires <br />Caldwell Systems <br />Piping Sumps/Vent Box Sum /Fill Riser Sum s/UDC's July 5, 2020 <br />❑ <br />❑ <br />❑ Secondary Pipe #8 <br />X <br />❑ <br />❑ <br />I CITMMARV OF TFCT RF,CITI,TC <br />Component <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs Component <br />Made <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />Annular Tank #1 <br />X <br />❑ <br />❑ <br />❑ Secondary Pipe #8 <br />X <br />❑ <br />❑ <br />❑ <br />Annular Tank #2 <br />X <br />❑ <br />❑ <br />❑ Secondary Pipe #9 <br />X <br />❑ <br />❑ <br />❑ <br />Annular Tank #3 <br />X <br />❑ <br />❑ <br />❑ Secondary Pipe #10 <br />X <br />❑ <br />❑ <br />❑ <br />Annular Tank #4 <br />X <br />❑ <br />❑ <br />❑ Secondary Pipe #11 <br />X <br />❑ <br />❑ <br />❑ <br />Annular Tank #5 <br />X <br />❑ <br />❑ <br />❑ Secondary Pipe #12 <br />X <br />❑ <br />❑ <br />❑ <br />Secondary Pipe #1 <br />X <br />❑ <br />❑ <br />❑ Piping Sump #1 <br />X <br />❑ <br />❑ <br />❑ <br />Secondary Pipe #2 <br />X <br />❑ <br />❑ <br />❑ Piping Sump #2 <br />X <br />❑ <br />❑ <br />❑ <br />Secondary Pipe #3 <br />X <br />❑ <br />❑ <br />❑ Piping Sump #3 <br />X <br />❑ <br />❑ <br />❑ <br />Secondary Pipe #4 <br />X <br />❑ <br />❑ <br />❑ Piping Sump #4 <br />X <br />❑ <br />❑ <br />❑ <br />Secondary Pipe #5 <br />X <br />❑ <br />❑ <br />❑ Piping Sump #5 <br />X <br />❑ <br />❑ <br />❑ <br />Secondary Pipe #6 <br />X <br />❑ <br />❑ <br />❑ Vent Box Sump <br />X <br />❑ <br />❑ <br />❑ <br />Secondary Pipe #7 <br />X <br />❑ <br />❑ <br />❑ Dispenser Sump #1&2 <br />X <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 />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:r�aDate: August 23, 2017 <br />