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SWRCB,January 2002 Page of <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, tivritten test procedures, and printouts from tests <br /> (if applicable), should be provided to the facility oivner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Nae: Kaiser Stockton Date of Testing: 12/6/2017 <br /> Name: <br /> Facility Address: 7373 WEST LANE,STOCKTON,CA 95210 <br /> Facility Contact: Kaiser Permanente-North Phone: <br /> Date Local Agency Was Notified of Testing: 11/9/2017 <br /> a <br /> Name of Local Agency Inspector(ifpresent during testing): <br /> 0 2017 <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name:Belshire Environmental Services,Inc. <br /> i <br /> Technician Conducting Test:Jeff Badders ENVII l Y t u$ / L °HMIA' l <br /> Credentials: ® CSLB Licensed Contractor 0 SWRCB Licensed Tank Tester ,... � <br /> License Type: A-General Engineering Contractor License Number:808313 <br /> Manufacturer Training <br /> Manufacturer Com onent(s) Date Training Expires <br /> See Aftac led <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> Tank Annulars 1 0 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> i <br /> Secondary Pie 2 0 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Piping Sum 1 ❑ 66 ❑ ❑ ❑ ❑ ❑ ❑ <br /> UDC ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Fill Sump ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Spill Bucket ❑ ❑ I ❑ ❑ ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> ❑ Placed in drums left on site for proper disposition. <br /> Transported to next site for use in additional testing. <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,the fads stated in this document are accurate and in full compliance tivith legal requirements <br /> Technician's Signature: (% 1 f _ o.(E'rr,y Date: 12/6/2017 <br /> a <br />