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1 0 iviDDDDD <br /> SWRCB,January 2002 Page I of <br /> TV 0 6 2009 <br /> Secondary Containment Testing Reportorm H <br /> This form is intended for use by contractors performing periodic testing of UST second �"T Use the <br /> appropriate pages of this form to report results for all components tested. The completed edures, 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 /> Facility Name: Kaiser Hospital Date of Testing: October 21,2009 <br /> Facility Address: 1777 West Yosemite Ave.,Manteca,Ca.95337 <br /> Facility Contact: Paul St.Onge I Phone: (209)825-3848 <br /> Date Local Agency Was Notified of Testing: 10/15/09 by Afford-a-Test <br /> Name of Local Agency Inspector(if present during testing): Not Present <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: R&D Compliance Testing <br /> Technician Conducting Test: Benjamin F.Duncan Jr. <br /> Credentials: ❑CSLB Licensed Contractor X SWRCB Licensed Tank Tester <br /> License Type: Tank Tester License Number:90-1120/ICC#5246802-UT <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> Annular Tank ❑ X ❑ ❑ ❑ ❑ <br /> Secondary Pipe 41 X ❑ ❑ ❑ ❑ ❑ ❑ <br /> Secondary Pipe 42 X I ❑ ❑ ❑ ❑ 1 ❑ ❑ <br /> Piping Sump X ❑ ❑ ❑ ❑ ❑ ❑ <br /> Spill Bucket X ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> Test Fluid Supplied and recovered for reuse by,R&D Compliance Testing. <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,the facts stated in this ument are accurate and In full compliance with legal requirements <br /> Technician's Signature:-�� 1 — Date: <br />