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Ll SWRCB, January 2002 ,,,III IillillillillIII� iiiiiiii v' Page of SEP 08 2014 Secondary Containment Testing Report Form This form is intended for use by contractors performing periodic testing of UST secondary containment appropriate pages of this form to report results for all components tested. The completed form, written t 94 printouts from tests (f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. 4. FACILITY INFORMATION Facility Name: Lodi Pacific Pride I Date of Testing: August 11, 2014 Facility Address: 351 North Beckman Rd., Lodi, Ca. 95240 Facility Contact: Ted Shackelford Phone: (209) 649-8308 Date Local Agency Was Notified of Testing: 8/5/2014, by Afford -A -Test Name of Local Agency Inspector (if present during testing): 5. TESTING CONTRACTOR INFORMATION 6 SUMMARY OF TEST RESULTS Component Pass Fail Not Tested Repairs Component Made Pass Fail I Not Tested Repairs Made Dispenser Sump # 3&4 X ❑ ❑ ❑ ❑ 1 ❑ ❑ ❑ Dispenser Sump # 5&6 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ Dispenser Sump # 7&8 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ Dispenser Sump # 9& 10 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ Fill Riser Sump #1 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ Fill Riser Sump #2 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ Fill Riser Sump #3 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ Fill Riser Sump #4 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ Fill Riser Sump #5 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ El ❑ ❑ ❑ If hydrostatic testing was performed, describe what was done with the water after completion of tests: Test Fluid Supplied and Recovered for reuse by, R&D Compliance Testing. 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: visa Date: August 11, 2014