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SWRCB,January 2002 Page 1. Secondary Containment Testing Report Form This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the appropriate pages of this form to report results for all components tested. The completed form, written test procedures,and printouts from tests(if applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. 1. FACILITY INFORMATION Facility Name: KAISER MANTECA Date of Testing: 08/07/2009 Facility Address: 1777 W YOSEMITE AVE MANTECA, CA, 95337 Facility Contact: JAMES BRAKKEE Phone: (2 0 9) 825-3460 Date Local Agency Was Notified of Testing: Name of Local Agency Inspector(if present during testing): MICHELLS 2. TESTING CONTRACTOR INFORMATION Company Name: TANKNOLOGY, INC. Technician Conducting Test: KRISTOPHER BELL Credentials: CSLB Licensed Contractor SWRCB Licensed Tank Tester License Type: License Number: 5297793-UT Manufacturer Training Manufacturer Component(s) Date Training Expires OPW 3. SUMMARY OF TEST RESULTS Not Repairs Not Repair Component Pass Fail Tested Made Component Pass Fail Tested Made Spill Box 1 DIE FILL FRI ❑ ❑ ❑ ❑ 1:1 ❑ 0- i ❑ I Ell ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ El- El ❑ ❑ ❑ ❑ ❑ ❑ El- F-1 El ❑ El ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ o ❑ ❑ ❑ ❑ ❑ ❑ ❑ Ell ❑ ELI ❑ ❑ ❑ ❑ ❑ ❑ ❑ El- El ❑ ❑ ❑ ❑ ❑ ❑ ❑ El El ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ 1:111:1 , El If hydrostatic testing was performed,describe what was done with the water after completion of tests: LEFT WATER IN DRUM ONSITE CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING To the best of my knowledge, the facts stated in this document are accurate and in full compliance with legal requirements Technician's Signature: .t-c Date: 08/07/2009