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RECEIVED <br /> Elite IV Contractors N O V C 5 2018 Page I of 2 <br /> Secondary Containment Testing Report Form <br /> This form is intended for use by contractors performing periodic testing of UST seep rt�Le <br /> kE "EYCE* <br /> appropriate pages of this form to report results for all components tested. The completed 'r�{{{� r edures, and <br /> printouts from tests(if applicable),should be provided to the facility owner/operator for su f A M egulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name Emils Liquor Date of Testing: 11/1/2018 <br /> Facility Address: 1405 California St Escalon Ca 95320 <br /> Facility Contact: Chako Phone:209-499-2693 <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(if present during testing): <br /> TA0249501 <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Elite IV Contractors <br /> Technician Conducting Test:Chris Adams <br /> Credentials: X CSLB Licensed Contractor SWRCB Licensed Tank Tester <br /> License Type: ICC California UST Service Technician License Number: <br /> Manufacturer Trainina <br /> Manufacturer Component(s) Date Training Expires <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledg the fa at in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: Date: / <br />