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0 <br />11 <br />E <br />SWRCB, January 2002 Page 1 of 1 <br />Secondary Containment Testing Report Form <br />This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the appropriate <br />pages of this form to report results for all components tested. The completed form, written test procedures, and printouts from tests <br />(if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />WyMOUVI- iais03tld/:V 11 [11 11 <br />Facility Name: KAISER MANTECA jDate of Testing: 8/16/2012 <br />Facility Address: 1777 W YOSEMITE AVE , MANTECA, CA 95337 <br />Facility Contact: ENGINEERING MANAGER Phone: 825-3460 <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agency Inspector (if present during testing): <br />2. TESTING CONTRACTOR INFORMATION <br />Name: TANKNOLOGY INC. <br />Technician Conducting Test: Steven Willems <br />Credentials: r CSLB Licensed Contractor r SWRCB Licensed Tank Tester <br />License Tvpe: tanknologv I License Number: 743160 <br />Manufacturer Training <br />Manufacturer Component(s) Date <br />II tanknoloev secondary containment 9/2/2013 1 <br />3_ CITMMARV OF TFAT RF,CiTT.T,,9 <br />Component <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />Component <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />Tank Annular# 1 <br />X <br />(Tank I - diesel) STP Containment 1 to ust <br />X <br />(Tank 1 - diesel) STP Containment 1 to ust <br />X <br />STP Containment for Tank I diesel - 1 <br />X <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: put in waterdog and take with <br />me <br />CERTIFICATION OF TECUMCIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my knowledge, the1 facts stated in this document are accurate and in full compliance with legal requirements <br />Technician's Signature: 7 w JQD,. Date: 8/16/2012 <br />WO: 2307392 <br />