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SWRCB,January 2002 Page of Secondary Containment Testing Report Form This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the appropriate pages of this form to report results for all components tested. The completed form, written test procedures, and printouts from tests(if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. 1. FACILITY INFORMATION Facility Name: Lodi Memorial Hospital I Date of Testing: October 24,2017 Facility Address: 975 South Fairmont Ave.,Lodi,Ca.95240 Facility Contact: Randy Roehrich I Phone: (209)339-7667 Date Local Agency Was Notified of Testing: 9/12/2017 Name of Local Agency Inspector(af present during testing): 2. TESTING CONTRACTOR INFORMATION Company Name: Afford-a-test Technician Conducting Test: Benjamin F.Duncan Jr./ICC#5246802-UT Credentials: X CSLB Licensed Contractor X SWRCB Licensed Tank Tester License Type: A License Number: CSLB Lic.#341375/SWRCB Lic.#90-1120 Manufacturer Training Manufacturer Component(s) Date Training Expires Caldwell Systems Piping Sump July 5, 2020 3. SUMMARY OF TEST RESULTS Component Pass Fail Not Repairs Component Pass Fail Not Repairs Tested Made Tested Made Annular Tank#1 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ Secondary Pipe#1 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ Secondary Pipe#2 X 1 ❑ ❑ ❑ ❑ ❑ 1 ❑ 1 ❑ Piping Sump#1 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ I ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ If hydrostatic testing was performed,describe what was done with the water after comp '.. P 1 sx Test Fluid Supplied and recovered for reuse. 2012 CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING To the best of my knowledge,the facts stated in this document are accurate and in ful a1 ei Technician's Signature: Date: October 24,2017