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SWRCB, January 2002 <br />Page of <br />Secondary Containment Testing Report Form <br />This form is intended for use by contractors performing periodic testing of UST secondary contain rnl systems. Use the <br />appropriate pages of this form to report results for all components tested. The completed form, written test procedures; and '' f <br />printouts from tests (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />A FACTT,TTV TNFnRMATTnN <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 (f present during testing): <br />5. TESTING CONTRACTOR INFORMATION <br />Company Name: Afford -a -test <br />Technician Conducting Test: Benjamin F. Duncan Jr. /ICC #5246802 -UT <br />Credentials: X CSLB Licensed Contractor X SWRCB Licensed Tank Tester <br />License Type: Tank Tester License Number: 90-1120 ffimm <br />Manufacturer Training <br />Manufacturer Component(s) Date Training Expires <br />Caldwell Svstems Piping SumpsNent Box/Fill Riser Sumps/UDC's July 5, 2017 <br />f_ SIIMMARV OF TF,ST 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 />Dispenser Sump # 3&4 <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Dispenser Sump # 5&6 <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Dispenser Sump # 7&8 <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Dispenser Sump # 9&10 <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Fill Riser Sump #1 <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Fill Riser Sump #2 <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Fill Riser Sump #3 <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Fill Riser Sump #4 <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Fill Riser Sump #5 <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 />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:wlm ✓ �` �� i Date: August 23, 2017 <br />