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SWRCB, January 2002 <br />Page 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 <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: KAISER MANTECA <br />Date of Testing: 08/13/2010 <br />Facility Address: 1777 W YOSEMITE AVE , MANTECA, CA, 95337 <br />Facility Contact: ENGINEERING MANAGER Phone: (209) 825-3460 <br />Date Local Agency Was Notified of Testing: 07/27/2010 <br />Name of Local Agency Inspector (if present during testing): NA <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: TANKNOLOGY, INC. <br />Technician Conducting Test: KELVIN <br />CRUZ <br />Component <br />Credentials: <br />El <br />CSLB Licensed Contractor <br />SWRCB Licensed Tank Tester <br />MM <br />License Type: CONTRACTOR <br />Manufacturer <br />I License Number: 743160 <br />Manufacturer Training <br />Component(s) <br />Date Training Expires <br />OPW <br />SPILL BKTS <br />11/04/2011 <br />_■�_00m0 <br />■W0m <br />3. SUMMARY OF TEST RESULTS <br />Component <br />Component <br />Spill Box I DIE FILL <br />MM <br />E <br />_■�_00m0 <br />■W0m <br />m000■m00 <br />mwmo <br />0000 <br />■oo0 <br />0000 <br />■000 <br />0000 <br />■000 <br />0000 <br />�■�0000��■�■aoo <br />■000 <br />0000 <br />����0000 <br />■■oo <br />��■■��■0000 <br />■■■�0000 <br />a000 <br />a000 <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />TOOK AS TEST WATER. <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: 08/13/2010 <br />