Laserfiche WebLink
RECEIVED <br /> SWRCB,January 2002 HiaX3 204 <br /> Secondary Containment Testing Report Form ENVIRONMENTAL <br /> This form is intended for use by contractors performing periodic testing of UST secondary containment systems. C>p4tFj)?ARTkAENT <br /> appropriate pages of this form to report results for all components tested. The completed form, written test procedures, and <br /> printouts from tests(f applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: City of Lodi/Lodi Corporation Yard Date of Testing: October 24,2017 <br /> Facility Address: 1331 South Ham Lane,Lodi,Ca.95241 <br /> Facility Contact: Randy Laney I Phone: (209)333-6830 <br /> Date Local Agency Was Notified of Testing: 9/12/2017 <br /> Name of Local Agency Inspector(fpresent during testing): <br /> 2. 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: A License Number: CSLB Lic.4341375/SWRCB Lic. 490-1120 <br /> Manufacturer Tr <br /> aiming <br /> Manufacturer Component(s) Date Training Expires <br /> Caldwell Systems Piping Sumps/UDC July 5,2020 <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 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Annular Tank#2 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Annular Tank#3 X ❑ ❑ ❑ ❑ ❑ ❑ 1 ❑ <br /> Secondary Pipe#1 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Secondary Pipe#2 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Secondary Pipe#3 ❑ X ❑ ❑ ❑ ❑ ❑ ❑ <br /> Piping Sump #1 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Piping Sump#2 ❑ X ❑ ❑ ❑ ❑ ❑ ❑ <br /> Piping Sump#3 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Dispenser Sump#1&2 ❑ ❑ X ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ El <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: �` �� Date: October 24,2017 <br />