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SWRCB, January 2002 Page 1. <br />Second9y Containment Testing Re rt Form <br />This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the <br />appropriate pages of this form to report results for all components tested. The completed form, written test procedures, and <br />printouts from tests (f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />FacilityName: KAISER MANTECA <br />Date of Testing: 08/03/2011 <br />Facility Address: 1777 W YOSEMITE AVE , MANTECA, CA, 95337 <br />Facility Contact: ENGINEERING MANAGER <br />Phone: (209) 825-3460 <br />Date Local Agency Was Notified of Testing: 07/28/2011 <br />Name of Local Agency Inspector (if present during testing): unknown <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: TANKNOLOGY, INC . <br />Technician Conducting Test: <br />JARROD COOKE <br />Component <br />Credentials: Q <br />CSLB Licensed Contractor ❑ SWRCB Licensed Tank Tester <br />Spill Box 1 DIE FILL <br />License Type: a <br />Manufacturer <br />License Number: 7 4 316 0 <br />Manufacturer Training <br />Component(s) <br />Date Training Expires <br />NA <br />000 <br />���0000 <br />aaoo <br />3. SUMMARY OF TEST RESULTS <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />taken water trailer <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: Date: 08/03/2011 <br />Component <br />Spill Box 1 DIE FILL <br />000 <br />���0000 <br />aaoo <br />� <br />o000 <br />0000 <br />0000 <br />0000 <br />��0000� <br />o000 <br />����0000 <br />aa�o <br />o000 <br />0000 <br />��0000 <br />0000 <br />0000 <br />0000 <br />0000 <br />■oor•�o <br />■���0000����0000 <br />� <br />0000 <br />0000 <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />taken water trailer <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: Date: 08/03/2011 <br />