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n <br />.J <br />SWRCB, January 2002 <br />of,, <br />Secondary Containment Testing Report Form <br />This form is intendedfor use by contractors performing periodic testing of UST secondary containment systeiruse*e <br />appropriate pages of this form 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: San Joaquin Hospital Engineering Plant Date of Testing: March 24, 2015 <br />Facility Address: 500 West Hospital Road, French Camp, Ca. 95231 <br />Facility Contact: Joe Bagley I Phone: (209) 468-3257 <br />Date Local Agency Was Notified of Testing: 2/10/2015, by Afford -A -Test <br />Name of Local Agency Inspector (present during testing): <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: R&D Compliance Testing <br />Technician Conducting Test: Benjamin F. Duncan Jr. <br />Credentials: 7 CSLB Licensed Contractor X SWRCB Licensed Tank Tester <br />License Type: Tank Tester License Number: 90-1120/ICC #5246802 -UT <br />Manufacturer Training <br />Manufacturer Component(s) Date Training Expires <br />Caldwell Systems Piping Sum /Fill Sump July, 2016 <br />3. SUMMARY OF TEST RESULTS <br />Component <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />Component Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />Annular Tank# i -Exempt <br />❑ <br />❑ <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Secondary Pipe #1 <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Secondary Pipe #2 <br />X <br />1 ❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />1 ❑ <br />1 ❑ <br />Piping Sump #1 <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Fill Riser Sump #1 <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />I ❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />I ❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />011❑ <br />❑ <br />❑ <br />❑ <br />1111El— <br />❑ <br />❑ <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />Test Fluid Supplied and recovered for reuse by, R&D Compliance Testing. <br />Annular Tank is Brine filled, and exempt form Periodic Testing. See Comments page #2. <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my knowledge, the facts stated in this document are accurate and in full compliance with legal requirements <br />Technician's Signature: assas� �T �tr9aQas� Date: March 24, 2015 <br />