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SWRCB, January 2002 Page 1. <br />Secondary Containment Testing Report Form <br />This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the <br />appropriate pages of this form to report results for all components tested. The completed form, written test procedures, and <br />printouts from tests (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />\ 7:7U /r V [4311 <br />Facility Name: PLAZA LIQUOR <br />Date of Testing: 11/11/2009 <br />Facility Address: 2420 W TURNER , LODI, CA, 95242 <br />Facility Contact: TOM GRAVES <br />Phone: (2 0 9) 369-1960 <br />Date Local Agency Was Notified of Testing : / / <br />Name of Local Agency Inspector (if present during testing): <br />2. TESTING CONTRACTOR O <br />Company Name: TANKNOLOGY, INC. <br />Pass <br />Technician Conducting Test: <br />JARROD COOKE <br />Repairs <br />Made Component <br />Credentials: <br />Fail <br />CSLB Licensed Contractor <br />Repair <br />Made <br />SWRCB Licensed Tank Tester <br />� <br />License Type: a <br />Manufacturer <br />I License Number: 743160 <br />Manufacturer Training <br />Component(s) <br />Date Training Expires <br />tanknology <br />all <br />07/18/2011 <br />❑ <br />Tank Annular 3 DIE <br />x <br />❑ <br />❑ <br />❑ <br />F 1 <br />El <br />3. SUMMARY OF TEST RESULTS <br />Component <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made Component <br />Pass <br />Fail <br />Not <br />Tested <br />Repair <br />Made <br />Tank Annular 1 REG <br />� <br />❑ <br />❑ <br />❑ UDC 1/2 <br />El <br />❑ <br />� <br />❑ <br />Tank Annular 3 DIE <br />x <br />❑ <br />❑ <br />❑ <br />F 1 <br />El <br />E <br />Secondary Pipe 3 DIE DIE <br />❑ <br />❑ <br />❑ <br />El <br />❑ <br />Secondary Pipe 2 SUP SUPEl❑ <br />� <br />1:1El <br />1-1 <br />El <br />Secondary Pipe 1 REG REG <br />❑ <br />El <br />El <br />❑ <br />❑ <br />❑ <br />F] <br />E <br />Piping Sump 1 REG <br />❑ <br />E <br />❑ <br />❑ <br />❑ <br />F I <br />❑ <br />Piping Sump 1 REG <br />X <br />❑ <br />❑ <br />Piping Sump 2 SUP <br />X <br />❑ <br />❑ <br />Piping Sump 2 SUP <br />❑ <br />El <br />El <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Piping Sump 3 DIE <br />El <br />F] <br />F] <br />El <br />El❑ <br />El <br />Piping Sump 1 REG <br />❑ <br />E <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />UDC 3/4 <br />El <br />❑ <br />a <br />❑ <br />❑ <br />❑ <br />❑ <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />taken water <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: Date: 11/11/2009 <br />