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V, SWRCB, January 2002 C] Page I of J Secondary Containment Testing Report Form VEDThis form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use t e appropriate pages of this form to report results for all components tested The completed form, written test pre la o r r , printouts from tests (f applicable), should be provided to the facility owner/operator for submittal to the local cy. 1. FACILITY INFORMATION Facility Name: LODI FOOD AND LIQUOR Date of Testing: Facility Address: 1225 W. LOCKEFORD STREET, LODI Facility Contact: PAUL Phone: 209-333-1038 Date Local Agency Was Notified of Testing: 12-20-10 Name of Local Agency Inspector (fpresent during testing): N/A 2. TESTING CONTRACTOR INFORMATION UMRONMENTAL Company Name: B.Z. Service Station Maintenance Technician Conducting Test: ED STEARNS Credentials: X CSLB Licensed Contractor _ ❑ SWRCB Licensed Tank Tester License Type: ICC License Number: 433159 Manufacturer Training Manufacturer Component(s) Date Training Expires INCON TS -STS o to F.1 trall If hydrostatic testing was performed, describe what was done with the water after completion of tests: CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING To the best of my knowledge, the facts stated in this document are accurate and in full compliance with legal requirements Technician's Signature: Date: 02-11-11 0000' 0�0® 1: 91 STP SUMP 1 DSL STP SUMPDOQO; : • 0�0�' ©000 oaoo©: DSL/91 ANNUALR mom 0000 000® 0000 000® mom= If hydrostatic testing was performed, describe what was done with the water after completion of tests: CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING To the best of my knowledge, the facts stated in this document are accurate and in full compliance with legal requirements Technician's Signature: Date: 02-11-11