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Appendix Vii <br />Underground Storage Tank <br />Secondary Containment Testing Report Form <br />TYPE OF ACTION ❑ Installation ❑ Repair ❑ 6 Month ® 36 Month <br />1. FACILITY INFORMATION <br />CERS ID <br />Test Date <br />.t n!e A PInIn <br />L 10181549 <br />Facility Name <br />City of LodilLodi Corporation Yard <br />Facility Address City ZIP Code <br />1331 South Ham Lane Lodi 95241 <br />2. SERVICE TECHNICIAN INFORMATION <br />Company Performing the Test Phone <br />RSD Compliance Testing 707 621-0378 <br />Mailing Address <br />P.O. Box 1503 Ukiah Ca. 95482 <br />Performing Test OCT 2 3 202 <br />Service Technician <br />Ben'amin Duncan <br />ContractorlTank Tester License Number ENVIRONMENTAL HEA <br />Tank Tester License #90-1120 PERMITISERVICES <br />ICC Number <br />]CC Expiration Date <br />52.46802 -UT <br />312112021 <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications <br />Expiration Date <br />Caldwell SystemslL.evel Change Indicator —_ <br />6/10/2023 <br />ICC Service Technician #5246802 -UT <br />3/21/2021 <br />Underground Storage Tank Tester License #90-1120 <br />12/3112022 <br />4. TEST PROCEDURE INFORMATION <br />Test Procedures Used <br />Components Tested <br />Vacuum <br />Tank Secondary Containment <br />Pressure <br />Product Piping Secondary Containment <br />Hydrostatic <br />Piping SumpslUDC's Y <br />S. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <br />I hereby certify that the secondary containment was tested in accordance with California <br />Code of Regulations, title 23, division 3, chapter 16, section 2637; that required supporting <br />documentation is attached; and all information contained herein is accurate. 1 understand <br />that test procedures shall be made available upon request by the governing authority. <br />_Total <br />Service Technician Signature Date # of Pages <br />10114/2020 5 <br />U <br />ri <br />CERS = California Environmental Reporting System, ICC = International Code Council, <br />ID = Identification, NA = Not Applicable, UDC = Under -Dispenser Containment, <br />Page t of 5 <br />