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12/22/2009 15:12 <br />SWRCB, January 2002 <br />2093651EO TANKNOLOGY --PAGE 01106 <br />Cid 3Page <br />Secondary Containment Testing Report Form <br />This form is intended for use by contractors performing periodic testing of UST secondary containment systems. ;tJ2 zoo <br />appropriate pages of this form to report results./or all components tested The completed forth, written test procedures, and <br />printouts from tests (if applicable), should be provided tot xe facility owner/operator for submittal to the locals � ° I� <br />TAL <br />I. FACILITY INFORMATION 4_11.lb ✓iV uEgAalu <br />Facility Name: PLAZA LIQUOR Date of Testing: 1j/ ; j1/2009 <br />Facility Address: 2420 W TURNER , LODI, CA, 95242 <br />Facility Contact: TOM GRAVES Phone: (209)369�19�0 <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agency Inspector (if present during testing): <br />2. TESTING CONTRACTOR INFORMATION ' <br />Company Name: TANKNOLOGY, ;NC . <br />Technician Conducting Test: JARROA COOKE <br />Credentials: IV I <br />CSLB Liccnsed Contractor ❑ SWRC13 Licensed Tank Tester <br />License Type: a License Number: 743160 <br />Manufacturer Training <br />p <br />Manufacturer <br />Com onent(s) Date',raining Expires <br />t:anknologrr all 07/18/2011 <br />I <br />%TTMMARY OF TEST RESULTS <br />Component <br />Pass <br />Not Repairs <br />pail 'Tested Made Component Pass <br />FIII <br />Not <br />Tested <br />Repair. <br />Tank Annular I REO <br />� - i <br />❑ ❑ F-1Unc 1/2 ❑ <br />❑ <br />❑ <br />❑ <br />I.:J <br />❑ <br />(Made <br />� <br />I of <br />❑ <br />Tank Annular 3 DTP <br />Secondary Pipe 3 DTE DIE <br />a <br />❑ ® ❑ <br />❑X El❑ ❑ <br />ED <br />❑ <br />S000ndary Pipe 2 SUE SUP <br />® <br />❑ ❑ ® ❑ <br />❑ <br />I��f <br />❑ <br />Secondary Pipe 1 REG REG <br />❑� <br />® ® C❑ <br />I " <br />❑ <br />1 1 <br />Piping Sump 1 REG <br />❑ <br />7X ❑ ❑ <br />LI <br />1 ❑ <br />❑ <br />Piping Sump l REG <br />i -- i <br />® <br />❑ ® ❑ ® <br />Piping sump 2 SUP <br />❑ ❑ ® El <br />-ELI <br />(®� <br />1I <br />0 <br />Piping Sump 2 SUPL] <br />❑X ❑ ❑ <br />❑ <br />L_ J <br />Piping Sump 3 DTE <br />Piping Sump 1 REO <br />�❑ <br />® ® L_l <br />j ❑� ❑ <br />j❑ <br />Ij� l <br />J <br />UDC 3 / 4 <br />t " J <br />��( <br />❑ ® l J ❑ <br />❑ <br />�❑'� <br />I—I <br />If hydrostatic testing was performed, dosorihe what was dont with the water after completion of tests: <br />taken water dog <br />CERT.IF'ICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING TI-hS TESTING <br />To the best of my knowledge, t(h, e facts stated in this document are accurate and in full compliance with lega� requirements <br />Technician's Signature:_"� _ Date: 11/11/200§ <br />