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4 SWRCB, 7anuary 2002 COPY Page of Seconda n ainment Testing Report Form This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the appjn e MED this form to report results for all components tested. The completed form, written test procedures, and printouts from tests (ifg, icable) should be provided to the facility ownedoperator for submittal to the local regulatory agency. IIYY vV 14 2005 1. FACILITY INFORMATION ENVIRONMENT HE TH Facility Name: Kaiser Permanente Hospital Date of Testing: 9MIMMIT/SERVIC Facility Address: 1777 Yosemite Avenue — Manteca Facility Contact: Bud McCauig @ Petro Analytical Phone: 925-528-9998 Date Local Agency Was Notified of Testing : 9/1/05 Name of Local Agency Inspector (if present during testing): None i 2. TESTING CONTRACTOR INFORMATION Company Name: CA. HAZARDOUS SERVICES,INC Technician Conducting Test: Randy Littlefield Not Tested Credentials: X CSLB Licensed Contractor X SWRCB Licensed Tank Tester License Type: Class A W/HAZ License Number: 734854 Manufacturer Manufacturer Training Component(s) Date Training Expires INCON STS SUMP TESTER 8/26/2007 ❑ ❑ ❑ ❑ ❑ 3. SUMMARY OF TEST RESULTS Component Pass Fail Not Tested Repairs Made Component Pass Fail Not Tested Repairs Made Spill Bucket X ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ j ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ 1 ❑ ❑ If hydrostatic testing was performed, describe what was done with the water after completion of tests: Left waste in drum on site. 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: CI