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is 0 <br />SWRCB, January 2002 <br />Page of <br />Secondary o tai a Testing eort For <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, written test procedures, and printouts from tests <br />(if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />Facility Name: Kaiser Stockton Date of Testing: 1/7/2 5 <br />Facility Address: 7373 WEST LANE, STOCKTON, CA 95210 <br />Facility Contact: Gardner, Darryl Phone: <br />Date Local Agency Was Notified of Testing: 12/19/2014 <br />Name of Local Agency Inspector (ifpresent during testing): <br />m�[v-T/`I /'1AnTTa1 a !'IT/!T TAT1"d"%" K A T4!!AT <br />a <br />G. 1L' ;311114`J 1.V11411`t11.1 V1` 1114r uiNIVII-111V114 UT7 H4wm <br />Company Name: Belshire Environmental Services, Inc. <br />Technician Conducting Test: Steve Reed <br />Credentials: ® CSLB Licensed Contractor ❑ SWRCB Licensed Tank Tester <br />License Type: A - General Engineering Contractor License Number: 808313 <br />WM <br />Manufacturer Training <br />Manufacturer Com onent(s) Date Training Expires <br />@@ Attached <br />1 11 1 1 1 , <br />MM <br />0000 <br />000 <br />MM-_ <br />�--_ <br />0=1411 <br />mmm0 <br />000 <br />MM__ <br />' <br />000 <br />0000 <br />',j <br />0 <br />■�OD <br />000 <br />Spill Bucket <br />00� <br />0000 <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 with legal requirements <br />Technician's Signature: c C2 Date: 1/7/2015 <br />