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SWRCB, January 2002 Page I of Secondary Containment Testing Report Form This form is intendedfor 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. i 9 MAD 10 b t u•�`7► Facility Name: Kaiser Hospital Date of Testing: October 21, 2009 Facility Address: 1777 West Yosemite Ave., Manteca, Ca. 95337 Facility Contact: Paul St.Onge Phone: (209) 825-3848 Date Local Agency Was Notified of Testing: 10/15/09 by Afford -a -Test Name of Local Agency Inspector (rf present during testing): Not Present i# 9 ski Y IME4111►11'MA-Med 1M to 113 lYll 11140 r ti N 10191 Company Name: R&D Compliance Testing Technician Conducting Test: Benjamin F. Duncan Jr. Credentials: ❑ CSLB Licensed Contractor X SWRCB Licensed Tank Tester License Type: Tank Tester License Number: 90-1120/ICC#5246802-UT Manufacturer Training Manufacturer Component(s)) Date Training Expires Fail Not Tested I Repairs Made Annular Tank u' ct sITIVan Component Pass Fail Not Tested Repairs Made Component Pass Fail Not Tested I Repairs Made Annular Tank ❑ X ❑ ❑ ❑ ❑ Secondary Pipe 41 X ❑ ❑ ❑ 1 1 ❑ 1 ❑ ❑ Secondary Pipe 42 X ❑ ❑ ❑ ❑ ❑ ❑ Piping Sump X ❑ ❑ ❑ ❑ ❑ ❑ Spill Bucket X ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ If hydrostatic testing was performed, describe what was done with the water after completion of tests: Test Fluid Supplied and recovered for reuse by, R&D Compliance Testing. CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING To the best of my knowledge, the facts stated in 11 is document are accurate and in full compliance with legal requirements 1 _ ... Date: ( Technician's Signature:::.. d