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Appendix Vil <br /> Underground Storage Tank <br /> Secondary Containment Testing Report Form <br /> TYPE OF ACTION ❑ Installation ❑ Repair ❑ 6 Month ® 36 Month <br /> 1. FACILITY INFORMATION —~ <br /> CERS ID T Test Date <br /> 10180611 10/16/2020 <br /> Facility Name <br /> Lodi Memorial Hospitol <br /> Facility Address City ZiP Code <br /> 975 South Fairmont Street TLodi 95240 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company <br /> R&D CompliancePlng the Tes# Test r � 07 621-0378 <br /> Mailing Address <br /> P.O. Box 1503 Ukiah Ca. 95482 q <br /> Service Technician Performing Test <br /> Benjamin Duncan NSA HEALTH <br /> Contractor/Tank Tester License Number pcnMt71SER <br /> Tank Tester License#90-1120 <br /> ICC Number ICC Expiration Date <br /> 5246802-UT 3/21/2021 <br /> 3. TRAINING AND CERTIFICATIONS j <br /> I Manufacturer and Test Equipment Training Certifications Expiration Date <br /> Caldwell Systems/Level Change Indicator 611012023 <br /> ICC Service Technician#5246802-UT 3121/2021 <br /> Underground Storage Tank Tester License#90-1120 1213112022 <br /> 4. TEST PROCEDURE INFORMATION <br /> Test Procedures Used v Components Tested <br /> Vacuum Tank Secondary Containment <br /> Pressure Product Piping Secondary Containment <br /> Hydrostatic I Piping Sump <br /> 5. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <br /> I hereby certify that the secondary containment was tested in accordance with California <br /> Code of Regulations, title 23, division 3, chapter 16, section 2637; that required supporting <br /> documentation is attached;and all information contained herein is accurate. ! understand <br /> that test procedures shall be made available upon request by the governing authority. <br /> Service Technician Signature Date Total#of Pages <br /> !3 D 10116/2020 - 5 --_---`-_�I <br /> CERS = California Environmental Reporting System, ICC = International Code Council, <br /> ID = identification, NA = Not Applicable, UDC = Under-Dispenser Containment, <br /> Page 1 of 5 <br />