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06 / 28 / 2019 19 : 29 8387674 EMILS PAGE 03 <br /> Page of <br /> SWRCB _ January 2002 <br /> -� . Secondary Containment Testing Report Form <br /> Phis forst is intended far use by contractors perform!goy o eels tdic ested the co coedary edforon written testnment procedures,Beeth and <br /> appropriate pages of this forth ro report results fora ! p <br /> printouts fr�o►n tests (if applicable), should be provided to the facility owner/op¢ratorfor submittal to the local regitlato►y agency. <br /> 1 . FACILITY INFORMATION <br /> Facility Name : Emil ' s Liquor & Sport7Shop/ChevronDate of Testg:320Facility Contact: Pamela <br /> Phone: 209) 838-7674 <br /> Date Local Agency Was Notified of resting : 6/ 13/2018 <br /> Name of Local Agency Inspector ('present du <br /> 2. TES'T'ING CONTRACTOR INFOItIVIATION <br /> E <br /> an Name: Afford-a-testnician Conducting Test_ Be <xlamin F. Duncan Jr. /ICC5246802-tJT <br /> Credentials: X CSLA Licensed Contractor X SWRCB Licensed Tank rester <br /> License Typo; A License Number : CSL13 Lic. 4341375/SWRC13 Lia 490 - 1120 <br /> turgeLT.Faiglax <br /> Trai <br /> Com onen s Date Trainin Ex IM <br /> Manufacturer July 5 2020 <br /> Caldwell SystemPi in g Sums/UDC ' s <br /> 3 . SU1VWA.RY OF TEST RESULTS <br /> Not Repairs <br /> Not lade <br /> s component Pass Fail e <br /> Component Pass Feil Tested p Tested Made <br /> Annular Tank # 1 ,2&3 X O 0Secondary Pipe # 1 ❑ Cl a l� <br /> Secondary Pi e #2 X ❑ Q Q 0 0 ❑ ❑ <br /> Secondary Pipe #3 X D 0 ❑ D 0 0 <br /> Pi IF Sum # 1 X 0 D 0 ❑ C1 ❑ U <br /> Piping Sump #2 X D 11 0 ❑ O D O <br /> P <br /> iping Sum #3 X ❑ U ❑ Cl 0 ❑ ❑ <br /> Dispenser Sump # 1 &2 X 0 0 0 Cl D ❑ <br /> Sum #3 &4 X 0 0 ❑ ❑ ❑ D ❑ <br /> ❑ ❑ D ❑ ❑ 0 00 <br /> 0 0Ll El <br /> ❑ jjE <br /> D ❑ 0 ❑ <br /> if hydrostatic testing was performed, dcscribe what was done with the water after completion of tests : <br /> Test Fluid Supplied and recovered for reuse. <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge, tine facts stated in this document are accurate and in full compliance with legal requirements <br /> r <br /> QQom�'' �` pate : u e 2 2� <br /> Technician' s Signature' . �fi fd � t <br /> Received Time Jun , 28 , 2019 7127PM No , 5223 <br />