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SWRCB,January 2002 Page of Secondary Containment Testing Report Form v � ® This form is intended for use by contractors performing periodic testing of UST secondary containment sys ems. 77se the appropriate pages of this form to report results for all components tested. The completed form, written to ��jj printouts from tests(if applicable), should be provided to the facility owner/operator for submittal to the 10rce ul te1 ency. 1. FACILITY INFORMATION ENVIRONMENT HEALTH Facility Name: Lodi Corporation Yard Date of Testing: Facility Address: 1331 S.Ham Lane,Lodi Ca 95241 D Facility Contact: Roger or Randy Phone: 209-3337683 Date Local Agency Was Notified of Testing Name of Local Agency Inspector(rf present during testing): EMVIR01977171 11u , , 2. TESTING CONTRACTOR INFORMATION PERN1I T iSE=R,V1SLS Company Name: JP Petroleum Service Technician Conducting Test: Gabriel Garcia Credentials: x CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester License Type: A License Number: 811471 Manufacturer Training Manufacturer Component(s) Date Training Expires 3. SUMMARY OF TEST RESULTS Component Pass Fail Not Repairs Not Repairs p Tested Made Component Pass Fail Tested Made Sump #1 Regular x ❑ ❑ ❑ UDC 5&6 x ❑ ❑ ❑ Sump #2 Regular x ❑ ❑ ❑ ❑ ❑ ❑ ❑ Sump#3 Diesel x ❑ ❑ ❑ ❑ ❑ ❑ ❑ Sump#4 Waste Oil x ❑ ❑ ❑ ❑ ❑ ❑ ❑ Line#1 Regular x ❑ ❑ ❑ ❑ ❑ ❑ ❑ Line#2 Manifold x ❑ ❑ ❑ ❑ ❑ ❑ ❑ Line#3 Diesel x ❑ ❑ ❑ ❑ ❑ ❑ ❑ Line#4 Waste Oil x ❑ ❑ ❑ ❑ ❑ ❑ ❑ Annular#1 Regular x ❑ ❑ ❑ ❑ ❑ ❑ ❑ Annular#2 Regular x ❑ ❑ ❑ ❑ ❑ ❑ ❑ Annular#3 Diesel x ❑ ❑ ❑ ❑ ❑ ❑ ❑ Annular#4 Waste Oil x ❑ ❑ ❑ ❑ ❑ ❑ ❑ If hydrostatic testing was performed,describe what was done with the water after completion of tests: Water was filtered and returned to holding tank. CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING To the best of my knowledge,the facts stated in this document are accurate and in full compliance with legal requirements Technician's Signature: Date: