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v SWRCB,January 2002 Secondary Containment Testing Report Form SEP 0 6 2016 This form is intended for use by contractors performing periodic testing of UST secondary containment appropriate pages of this form to report results for all components tested. The completed form, written duty printouts from tests (f applicable), should be provided to the facility owner/operator for submittal to the 1. FACILITY INFORMATION Facility Name: Sutter Tracy Community Hospital Date of Testing: August 8,2016 Facility Address: 1420 North Tracy Blvd.,Tracy,Ca.95367 Facility Contact: Pedro Gonzalez I Phone: (209)832-6032 Date Local Agency Was Notified of Testing: 7/11/2016 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: L-CSLB Licensed Contractor X SWRCB Licensed Tank Tester License Type: Tank Tester License Number: 90-1120/ICC#5246802-UT Manufacturer Training FCaldwell acturer Component(s) Date Training Expires ystems Piping Sump July 30, 2017 3. SUMMARY OF TEST RESULTS Not Not Repairs Component Pass Fail Tested Repairs Made Component Pass Fail Tested Made Annular Tank#I X ❑ ❑ ❑ ❑ ❑ ❑ ❑ Secondary Pipe#1 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ Secondary Pipe #2 X ❑ ❑ ❑ ❑ ❑ 1 ❑ ❑ Secondary Pipe #3 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ Secondary Pipe #4 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ Secondary Pipe#5 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ Piping Sump#1 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ I ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ If hydrostatic testing was performed,describe what was done with the water after completion of tests: Test Fluid Supplied and recovered for reuse by,R&D Compliance Testing. 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: 'AW m� Date: August 8,2016