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. t 0 R4E1Vt=L) <br /> wlo#: l6ososass <br /> S W KC B,January 2002 SEP 2016 page 1 of 7 <br /> Secondary Containment Testin EALTH <br /> This Porn:is intended for use by contractors performing periodic testing of GIST secondar Ins. Ilse the <br /> appropriate pages of this Porn:to report results for all components tested The completed arm, 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 /> 1.FACILITY INFORMATION <br /> Facility Name: KINGCA Mid City Ca FO Regen I Date of Testing: 9/7/16 <br /> Facility Address: 13850 Devries Road Lodi CA <br /> Facility Contact: MASOOD CHOUD.HURRY Phone:909-6134553 <br /> Date Local Agency was Notified of Testing: <br /> Naive of Local Agency Inspector Present ffliresent iluriq testing): NA <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: SunWest Engineering Constructors,Inc. <br /> 1 Technician Conducting Test: Leonardo Aguilar <br /> Credentials: ®CSLB Licensed Contractor SWRCB Licensed Tank Tester <br /> License Type: General Engineering"A" License Number: 703190 <br /> { Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> j INCON TS-STS 1.1/23/17 <br /> OWENS CORNING UST NEVER EXPIRES <br /> I <br /> { <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Repairs Com Not Repairs <br /> Component Pass Fail Tested Made Component Pass Fait Not <br /> Made <br /> FILL SUMP ❑X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> SUPPLY LINE ❑X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> RETURN LINE ❑X, ❑ ❑ ❑ ❑ ❑ ' ❑ ❑ <br /> VENT LINE 0 1 ❑ 1 ❑ ❑ ❑ ® ❑ ❑ <br /> VENT BOX Q I ❑ I ❑ ❑ ❑ ❑ I ❑ ❑ <br /> PIPING VAULT x ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ANNULAR SPACE Q ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ [--] 1, ❑ ❑ <br /> 1:1 El ❑ ❑ El ❑ 1 ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ 1 ❑ <br /> El El ❑ ❑ 11 El ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> rRAASPCQRiEIL II-%NEXT.ECTI,hG c![JLICY <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To lite best of my knowledge,the facts stated in this document are accurate and in full compliance with legal requirements <br /> Dighllys nedbyLeon8rkAgu9arbrW1'llNK5459 <br /> Technician's Signature: 09001N:032 Date:9/7116 <br /> Revision: QA/QC APPROVED <br /> 9/7/20164:22 PMBrandon Bo <br />