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SWRCB, January 2002 L 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 tesi procedures, and printouts from tests (f applicable), should be provided to the facility owner/operator for submittal to the local regulatory dgehq 1. FACILITY INFORMATION Facility Name: Sutter Tracy Community Hospital Date of Testing: August 16, 2013 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: 7/24/13 by, Afford -A -Test Name of Local Agency Inspector (if present during testing): Component Pass Fail Not Tested Repairs Component Made Pass Fail Not Repairs Tested Made Annular Tank #1 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ Secondary Pipe 41 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ Secondary Pipe #2 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ Secondary Pipe #3 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ Secondary Pipe 44 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ Secondary Pipe#5 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ Piping Sump 41 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ 1 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ 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:Date: August 16, 2013