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2098253893 ENGINEERING DEPT. <br />SWRrR tan 70n2 <br />1104 a.m. 08-27-2009 15/17 <br />Secondary Containment Testing Report Form <br />This form is intended for use by contractors performing I periodic testing of UST secondary containment systems. Use the <br />appropriate pages q)(thiBform to report results for all components tested. The completed form, written test procedures, and <br />1rintoutsfrom tests (7f applicable), should be provided to the facility ownerloperatorfor submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />FacilityNan-Lc: KAISER MANTECA =DateofTesting: 08/11/2009 <br />r1acility Ad&CSS: 1777 W YOSEMITE AVE MANTECA, CA, 93337 <br />Facility Contact: JAMES ERAKKEEho'ne: (209) 825-3460 <br />Date Local Agency Was Notified of Testing: / . <br />Namc of Local Agency Inspector (if present during testing): <br />2. TESTING CONTRACTOR INFORMATION <br />3. SUMMARY OF TEST RESULTS <br />If hydrostatic testing was Performed, describe what was done with the water after completion of tests: <br />taken water dog <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best qj'my knowledge, the facts .stated in this document are accurate and infill compliance with legal requirements <br />Technician's Signature: P-:�z Date: 08/1l/2009 <br />I <br />