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SWRCB, January 2002 0 Secondary Containment Testing Report Form Page of This form is intended for use by contractors performing periodic testing of UST secondary contaiwuent systems. Use the appropriate pages of this form to report results for all components tested. The completed form, written test procedures, and printouts front tests (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. 1. FACILITY INFORMATION Facility Name: Stockton Medical Center I Date of Testing: 1/16/2014 Facility Address: 7373 WEST LANE, STOCKTON, CA 95210 Facility Contact: Gardner, Darryl Phone: Date Local Agency Was Notified of Testing: 1/15/2014 Name of Local Agency Inspector (ifpresent during testing): 2. TESTING CONTRACTOR INFORMATION Company Name: Belshire Environmental Services, Inc. Technician Conducting Test: Jeffrey Badders Credentials: ® CSLB Licensed Contractor ❑ SWRCB Licensed Tank Tester License Type: A - General Engineering Contractor License Number: 808313 Manufacturer Training Manufacturer Comvonent(s) Date Training Expires ee Aftac Component Pass Fail Not Tested Repairs Made Component Pass Fail Not Tested Repairs Made Tank Annulars ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ Secondary Pie ❑ ❑ ❑ I ❑ ❑ ❑ ❑ I ❑ Piping Sum i ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ UDC ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ Fill Sump ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ Spill Bucket ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ [I Placed in drums left on site for proper disposition. 91 Transported to next site for use in additional testing. CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING To the best of my knowledge, the fads stated in this document are accurate and in full compliance with legal requirements Technician's Signature: r-� 1-7/1 ''' Date: 1/16/2014