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SWkCB,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(if applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: KAISER MANTECA Date of Testing: 11/05/2010 <br /> Facility Address: 1777 W YOSEMITE AVE , MANTECA, CA, 95337 <br /> Facility Contact: ENGINEERING MANAGER Phone: (2 0 9) 825-3460 <br /> Date Local Agency Was Notified of Testing: 11/01/2010 <br /> Name of Local Agency Inspector(if present during testing): None <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TANKNOLOGY, INC. <br /> Technician Conducting Test: JARROD COOKE <br /> Credentials: CSLB Licensed Contractor SWRCB Licensed Tank Tester <br /> License Type: a License Number: 743160 <br /> Manufacturer TraininE <br /> Manufacturer Component(s) Date Training Expires <br /> tanknology all 07/17/2011 <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Repairs Not Repair <br /> Component Pass Fail Tested Made Component Pass Fail Tested Made <br /> Secondary Pipe 1 DIE RETURN M ❑ ❑ ❑ ❑ F-1 u ❑ <br /> Piping Sump 1 DIE x ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ F� ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> El- <br /> El❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> o ❑ ❑ ❑ ❑ Ell ❑ ❑ <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 of my knowledge, thhe/facts stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: Date: 11/05/2010 <br />