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SWRCB,January 2002 Page of <br /> Secondary Containment Testing Report Form <br /> This form is intended for use by contractors performing periodic testing of UST secondary containment 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(f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Lodi Memorial Hospital Date of Testing: 11/2/05 <br /> Facility Address: 975 S.Fairmont Lodi Ca 95241 p <br /> Facility Contact: Randy,Maint. Supervisor Phone: 209-339-7661 VJ <br /> Date Local Agency Was Notified of Testing <br /> Name of Local Agency Inspector(f present during testing): <br /> ENVhu ;k..ALTH <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: JP Petroleum Service <br /> Technician Conducting Test: Gabriel Garcia <br /> Credentials: x CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester <br /> License Type: A License Number: 811471 <br /> Manufacturer Training <br /> Manufacturer Coon nen s Date Training Expires <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> Sump#1 x ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Line#1 x ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Line#2 x 1 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Annular Space#1 x ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> Water was filtered and returned to holding tank. <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,the facts tated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: �l Date: <br />