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SWRCB,January 2002 Page: of , <br /> Secondary Containment Testing Report Form G4 014 <br /> This form is intended for use by contractors performing periodic testing of UST secondary containment systems. se t e <br /> appropriate pages of this form to report results for all components tested. The completed form, written test procedures, and <br /> Printoutsfom tests cifaPhcable)� should be provided to thefacility owner/oPeratorfor submitt o -" to y 3g@ ��QLTHh <br /> 1. FACILITY INFORMATION <br /> Facility Name: Lodi Memorial Hospital I Date of Testing: October 9,2014 <br /> Facility Address: 975 South Fairmont Ave.,Lodi,Ca.95240 <br /> Facility Contact: Randy Roehrich I Phone: (209)339-7667 <br /> Date Local Agency Was Notified of Testing: 9/17/2014,by Afford-A-Test <br /> Name of Local Agency Inspector(if present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: R&D Compliance Testing <br /> Technician Conducting Test: Benjamin F.Duncan Jr. <br /> Credentials: ❑CSLB Licensed Contractor X SWRCB Licensed Tank Tester <br /> License Type: Tank Tester License Number: 90-1120/ICC#5246802-UT <br /> Manufacturer Training <br /> Manufacturer Component(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 /> Annular Tank#1 X ❑ ❑ ❑ 0 ❑ 0 ❑ <br /> Secondary Pipe#1 X ❑ ❑ ❑ ❑ 0 0 ❑ <br /> Secondary Pipe#2 X ❑ ❑ ❑ ❑ 0 ❑ 0 <br /> Piping Sump#1 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ 0 ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ 0 ❑ 0 ❑ ❑ ❑ ❑ <br /> ❑ ❑ 0 ❑ ❑ ❑ 0 ❑ <br /> 0 0 0 0 ❑ ❑ 0 ❑ <br /> 0 0 0 0 0 0 0 0 <br /> ❑ 0 0 ❑ 0 0 0 ❑ <br /> ❑ ❑ ❑ 0 ❑ 0 ❑ 0 <br /> 0 ❑ 0 0 ❑ 0 0 0 <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 by,R&D Compliance Testing. <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: .�YJ�rafam�telJusa�saDate: October 9,2014 <br />