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r 2/2 <br /> SWRCB,Jammq 2002 I ._of_ <br /> Secondary Containment Testin <br /> 1 his form is intended for use by contractors performing pello&testing of n i en. <br /> appropriate pages ofthis form to report results for all eompmtents tasted The com ete Jorm,written test prooe res,and <br /> printouts from tests af'appOcablaj,should be provided to the facility mvtterloperamr for subngi jt t? e� regulatory agency. <br /> 1 ✓ <br /> 'I. FACILITY INFORMATION <br /> Faci]i Name: Kaiser Permanente Date of T : 7-7-2015 <br /> Fadlity Addr=7373 West Lane Stodton,CA 95210 , i L a I AL M Lk <br /> Facility Contact:Russett Langley Pbone: . `M E NT <br /> Date Local! .M Was MOW of Taft: 7-3-2015 <br /> Name of Local Agency Inspector(lfpresent during resit e:Patinah Zareef RBHS <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Compaw Nam: Wilke 's Construction Inc, <br /> Techaidan 2nftft Test: Dale Adam <br /> Creden ials: M dLB Licensed Conuumt U SWRCB Lke med Tank Tester <br /> License : A HAZ B Lioam. Number.722945 <br /> M or T�bii�o_ <br /> h9aanfattet Co s Date <br /> t"SEE ATTACHED** <br /> 3. SUABIARY OF TEST RESULIS <br /> component pin Fra Ill Tested Not component Pas Iran Not <br /> R <br /> MadeP!ging Surnp 1 1t u L1 u u u u u <br /> u u u u u u u u <br /> u u u u u u u u <br /> u u u u u u u u <br /> u u u u u u u u <br /> u u u u u u u u <br /> u u u u u u u u <br /> u u u u u u u u <br /> u u u u u u u u <br /> u u u u u uL u u <br /> u u u u u u u u <br /> u u u u u I u u u <br /> If hydrmWo testing was perfb=4 describe what was done with the water aft completion of tests: <br /> Placed in drums,left on site for proper disposal. <br /> CERTWJCATICIN TE WZdClAN R>i;SPONSXBL IFIOOR CONDUCTING THIS TESTING <br /> To the bed of nW An. e j fu�k are aomu*and lea feeg aonrUm es ttM legal regalrame nes <br /> Technic s S Date: '— <br /> ( 16563? <br />