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• <br />SWRCB, January 2002 <br />. IW/O#:l 130726--13 <br />Secondary Containment Testing Report Form <br />Page I of 7 <br />This form is intended for use by contractorsperformingperiodic testing of UST secondary containment systems. Use the <br />appropriate pages of thisform 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 />1. FACILITY INFORMATION <br />Facility Name: KINGCA Mid City Ca FO Regen I Date of Testing: 9/12/13 <br />Facility Address: 13850 Devries Road Lodi CA <br />Facility Contact: Jonathan Pakele Phone: 916-439-6042 <br />Date Local Agency Was Notified of Testing: 48 hours prior <br />Name of Local Agency inspector Present (f present during testing): Inspector Aris <br />7_ TERTINC.rnNTRACTOR INFORMATION <br />Company Name: SunWest Engineering Constructors, Inc. <br />Technician Conducting Test: Leonardo Aguilar, Spencer Kissick <br />Credentials: N 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 />INCON TS -STS 7-15-15 <br />Owens-Corning UST NEVER <br />3. SUMMARY OF TEST RESULTS <br />Component <br />0000 <br />ar�r�r� <br />Fill Sump <br />naor■� <br />0000 <br />Piping Trench <br />normo <br />0000 <br />novo <br />0000 <br />pill Bucketnovo <br />0000; <br />Supply line <br />0000 <br />ocaoo <br />Vent line ' <br />0000 <br />0000 <br />Return line secondary <br />0000 <br />MMM�Mmwlm <br />0000 <br />0000 <br />0000, <br />0000 <br />0000� <br />-- <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />I .Pft nn Site in driomt, t1n7mnt Pi-l:iyp firkpt rated Tirknt number 112.SRM1 <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my knowledge, the fads stated in this document are accurate and in full compliance with legal requirements <br />DOW11 §r 4SpwrlG dfor PEW <br />Technician's Signature: Date: 9/12/13 <br />Revision: QA/QC APPROVED <br />9/13/20133:39 PMMike P. B <br />