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0 9 <br /> Secondary Containment Testing Report Form <br /> This <br /> fi)rrn is intended fin-use by conlractors peijbrmiitq periodic testing,Qf UST secondary eontuinnient systents. t1se the <br /> prinfoutsftonl tests(zI'qpplicahle),should be provided to thefitc-ility ownerloperatorfiar submittal to the local regulatory agency. <br /> 1. FACILITY INFO—RMATION <br /> Facility Name: LORI FOOD& Date of Testin 9 2/5/2014--- <br /> Facility Address: 1225 W LOCK FORD, LODI Countv SAN JOAQUIN <br /> facility <br /> P <br /> lie: 209-333-1038 <br /> Contact: PAL ................ <br /> ........... <br /> Date Local Agency Wats .... <br /> s Notified of Tuesday,January 07,2014 <br /> ........ ........ <br /> Name of Local Agency I nspcctor(if present during tcsfitq): NONE <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: B.Z.Service Station Maintenance <br /> ................................... <br /> Technician Conducting'rest: ALE XANDERTATE <br /> Credential;,. Z CSLB Licensed Contractor SWRC13 Licensed Tank rester <br /> .................. ..............---- <br /> License Type: lCC Lie rise Number-.433159 <br /> EEO <br /> Manufacturer_"r�rainin <br /> Manufacturerorn)}nent(s) Dt to Tr it it Lx ire's <br /> .............. <br /> INCON TS-STSAUG 2.10.1-5 <br /> ........................... <br /> .............. .......................................... ............. <br /> ................ .......... <br /> 3. SUMMARY OF TEST RESULTS <br /> -777—Neat 7We`p`aiis Not Repairs <br /> Component Pass Fail ' Component :•Pass Fail <br /> T <br /> Component Made Tested Made <br /> 87 STP SUMP 91 ST11 SUMP . ........... <br /> DSL STP SUMP El 87 ANNULAR <br /> .......... .................................................... ........... <br /> DSL ANNULAR <br /> A.N.N� ULAR-........... ............. -------------- <br /> 87 SEC LINE 91 SEC LINE <br /> QS1... SEC LINE .� Cl ............ UDC. 1i2 1/21 ................... <br /> UDC 3/4 <br /> I VE-1 V LZU <br /> Ul*)*C 7/8 <br /> El <br /> 7"D <br /> -j <br /> rT <br /> --—--------------------........ ................... <br /> ❑ <br /> ..............I Eli Eli 11 M- ENWRONMEN....- <br /> I F-11 F1 El [j <br /> .......... .......... <br /> I Eli El El El 7 1.jD J-E] I <br /> If hydrostatic testing was performed,describe what was donevvith the water after completion of texts: <br /> . <br /> -............. .............................. ...... .......... --——--------- <br /> TOOK AS TEST WATER <br /> ------------- ............................L...................... .................. --—-—------------ <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the hest of nkv knowledge,thefacostated in this document art,accurate and in Dull compliance with legal requirements <br /> Technician's <br /> Date:2/5/2014 <br /> ...............-.......... <br /> Secondary Containment Test Results I of <br /> ....................... ........ ............. ................................................ <br />