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19 SWRCB, January 2002 Page of Secondary Containment Testing Report Form This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the appropriate pages of this form to report results for all components tested. The completed form, written test procedures, and printouts from tests (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. 1. FACILITY INFORMATION Facility Name: Kaiser Hospital Date of Testing: 11/21/2013 Facility Address: 7373 West Lane, Stockton, Ca. 95210 Facility Contact: David Catanzarite Phone: (209) 476-3413 Date Local Agency Was Notified of Testing: 10/24/13, by Afford -A -Test Name of Local Agency Inspector (f present during testing): 2. TESTING CONTRACTOR INFORMATION Company Name: R&D Compliance Testing Technician Conducting Test: Benjamin F. Duncan Jr. Credentials: ❑ CSLB Licensed Contractor X SWRCB Licensed Tank Tester License Type: Tank Tester License Number: 90-1120/ICC #5246802 -UT Manufacturer Training Manufacturer Component(s) Date Training Expires EVA -1 0 -KIT., e7�111 �fy11�7 Di.Yll'N Ify Component Pass Fail Secondary Pipe #I -Supply X ❑ Secondary Pipe #2 -Return X ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ 1 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ Not Tested Repairs Component Made Pass Fail Not Tested Repairs Made ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ 1 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ If hydrostatic testing was performed, describe what was done with the water after completion of tests: CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING To the best of my knowledge, the facts stated in this document are accurate and in full compliance with legal requirements Technician's Signature: �m,�a�Jtr�acasa,k Date: November 21, 2013