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IF DE e IF UNIDERGROUNp STORA1 1dGE TANK: ©J . ;SECONDARY CONTAINMENT .TESTING REPORT FORK) (Page 1 of`6) . , Type of Action ❑ installation Test ® Repair Test ❑ Six Month Test ❑ 36 Month Test 1 111, 1; FACILITY INFORMATION CERS ID Date of Secondary Containment Test 10181559 112/6/2018 Business Name (Same as Facility Name or DBA-Doing Business As) Kaiser Manteca Medical Center Business Site Address City ZIP Code 1777 W. Yosimite Avenue I Manteca 95337 . II 1 . 1. UN RGROUND STORAGE TANK SERVICE TECHF 9 NIC, IAN ;INFOR MAT9. ION '. . 91 F Name of UST Service Technician Performing the Test (Print as shown on the ICC Certification) Phone # Saul Gonzalez I 949460-5200 Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date 808313 Class A 5254881 111, SUMMARY OF 4 4SECONDARY CONTAINMENIF T:?ESTING,:RESULTS TANK ID: (By tank number, stored product, etc,) A Diesel B C D IF IF t4 , Tank Containment EFILF = _ _ IF IF �� Tightness Test Result ❑ Pass ❑ Fall [INA ❑ Pass ❑ Fail ❑ NA [] Pass ❑IFail [INA �❑�Pass Ll Fail ❑ NA Product Piping Containment 3E - IF P g Cit " m F _ _ Tightness Test Result ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass [] Fall ❑ NA ❑ Pass ❑ sFall ❑ NA Communication Test Result ❑ Pass ❑ Fail [INA ❑ Pass ❑ Fail [INA ❑ Pass ❑ Fall [INA ❑ Pass ❑ Fail ❑ NA µ ' = Remote FIII Piping Containment _ Tightness Test Result F ❑ Pass ❑ Fall ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass (❑ Fall ❑ NA ❑Pass ❑ Fail 0 NA Communication Test Result ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ` 111,,1--c=am - s - FFF1 s . ' - c' =" ' _:. Vent Piping Containment = . Tightness Test Result ❑ Pass [:] Fall ❑ NA ❑ Pass ❑ Fail [INA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA Communication Test Result ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA [I Pass ❑ Fall ❑ NA 4 IF Vapor Recovery Piping Containment y" _ x r " _`FFIz � IF z Tightness Test Result [] Pass E] Fall ❑ NA [IPass ❑ Fall [INA ❑ Pass Q] Fail ❑ NA ❑Pass ❑ Fail ❑ NA Communication Test Result ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail [INA ❑ Pass [] Fail ❑ NA ❑ Pass ❑ Fall ❑ NA Turbine / Product Piping Sump ==IN z _ffl � Tightness Test Result M Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass [] Fall ❑ NA ❑ Pass ❑ Fail ❑ NA Fill Riser Sump ONE Tightness Test Result [] Pass ❑ Faii ❑ NA [I Pass ❑ Fail ❑ NA ❑ Pass d] Fail ❑ NA ❑ Pass ❑ Fail ❑ NA i VENT I TRANSITION SUMP ID: a b C d FF Tightness Test Result [:] Pass ❑ Fail ❑ NA ❑ Pass [I Fail ❑ NA ❑ Pass E] Fall ❑ NA ❑ Pass ❑ Fail ❑ NA UDC ID : 1 2 3 4 Tightness Test Result [] Pass ❑ Fail ❑ NA ❑ Pass ❑ Fall [INA ❑ Pass ❑ Fall ❑ NA ❑ Pass ❑ Fail ❑ NA i uoc ID : 5 6 7 8 Tightness Test Result ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ FailIONA ❑ Pass (:] Fail ❑ NA ❑ Pass ❑ Fail [INA UDC ID : 9 10 11 12 Tightness Test Result ❑ Pass ❑ Fall ❑ NA ❑ Pass [I Fall ❑ Pass ❑ Fail [INA ❑ Pass ❑ Fail ❑ NA All Items marked "Fall" or "NA " must be explained In their respective "COMMENTS" section. IV : CERTIFICATION SYUSTSSRVIGE TECHNICIAN :CONDUCTING THIS . TESTING I hereby certify that the secondary containment was tested In accordance with California Code of Regulations, Title 23, Division 3, Chapter 16, Section 2637 and all the information contained herein is accurate. UST Service Technician Signature CERS = California Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = International Code Council, NA = Not Applicable, UDC = Under- Dispenser Containment