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2098253893 ENGINEERING DEPT. 0 0 :17 a.m. 09-10-2010 7121 <br /> SWRCB,January 2002 Page 1. <br /> Secondary Containment Testing Report Form <br /> This form is intended for use by contractors performing periodic testing of UST secondary containment systems: Use the <br /> appropriate pages of this form to report results for all components tested. The completed form,written test procedures,and <br /> printouts from tests(�f applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> FacilityName: KAISER MANTECA DateofTesting: 08/13/2010 <br /> Facility Address: 1777 W YOSEMITE AVE MANTECA, CA, 95337 <br /> Facility Contact: ENGINEERING MANAGER k Phone: (209) 825-3460 <br /> Date Local Agency Was Notified of Testing: 07/27/2010 <br /> Name of Local Agency Inspector(if present during testing): NA <br /> 2. TESTING.CONTRACTOR INFORMATION <br /> Company Name: TANKNOLOG , INC. <br /> Technician Conducting Test: KELVIN CRUZ <br /> Credentials: CSLB Licensed Contractor ❑ SWRCB Licensed Tank Tester <br /> License Type: CONTRACTOR License Number: 743160 <br /> Manufacturer Training <br /> Manufacturer , Component(s) Date Training Expires <br /> OPW2 SPILL BKTS 11/04/2011 <br /> C SUMMARY OF TEST RESULTS <br /> Not Repairs Not Repair <br /> Component Pass Fail Tested Made Component Pass Fail Tested Made <br /> Spill Box 1 DIE FILL 0 ❑/ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ El- <br /> El <br /> ❑ ❑ ❑ ❑ ❑I ❑ <br /> '❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ® ❑ <br /> ❑ E3 ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ - <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> El I ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ p❑ I ❑ ❑ ❑ ❑I ® ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> TOOK AS TEST WATER. <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,the facts stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: G�-<-� Date: 68/13/2010 <br /> .4 <br />