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SWRCB, January 2002 Page 1. <br />Second y Containment Testing ReArt 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 (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />FacilityName: KAISER MANTECA <br />Date of Testing: 08/30/2007 <br />Facility Address: 1777 W YOSEMITE AVE , MANTECA, CA, 95337 <br />Facility Contact: JAMES BRAKKEE <br />Phone: (2 0 9) 825-3460 <br />Date Local Agency Was Notified of Testing: 08/20/2007 <br />Name of Local Agency Inspector (if present during testing): Muniappa Naidu <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: TANKNOLOGY, INC. <br />Technician Conducting Test: <br />DOUG FALDE <br />Credentials: <br />CSLB Licensed Contractor <br />El <br />SWR C13 Licensed Tank Tester <br />License Type: I CC <br />I <br />License Number: 5307847 -UT <br />Manufacturer <br />Manufacturer TraininE <br />Component(s) <br />Date Training Expires <br />OPW <br />All <br />��00 <br />aoo <br />3. SUMMARY OF TEST RESULTS <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />RECLAIMED FOR REUSE <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: J= Date: 08/30/2007 <br />Spill Box I DIE FILL_ <br />000 <br />��00 <br />aoo <br />0000 <br />0000 <br />0000 <br />0000 <br />0000 <br />0000 <br />0000 <br />0000 <br />0000 <br />0000 <br />0000 <br />0000 <br />0000 <br />a000 <br />a000 <br />0000 <br />a000 <br />0000 <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />RECLAIMED FOR REUSE <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: J= Date: 08/30/2007 <br />