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From','Beishire Environment Fax: (949) 4MS21 0 <br />SWRCB, January 2002 <br />To: 12094683433@rcfax.cc Fax: +12094683433 <br />Page 2 of 8 OM=01 5 9:23 AM <br />Page _ of <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 appropriate <br />pages of this forret to report results for all components tested The completed farm, written test procedure. and printouts front tests <br />Of applicable), should be provided to the facility ownerloperatorfor submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: Kaiser Manteca - - - - I Date of Testing: 8/7/2015 <br />Facility Address: 1777 W. YOSEMITE AVENUE, MANTECA, CA 95336 <br />Facility Contact: Corbin, Sam Phone: <br />Date Local Agency Was Notified of Testing: 7/16/2015 <br />Name of Local Agency Inspector (1fpresent during testing): AIM 0 Q 9m; <br />1 -r",-1VT1kTr4 A-1^WVr" A lr&T"^"% AFA 'Vlr^&T <br />3. SUMMARY OF TEST RESULTS <br />Component Pass Fag Not Repairs Component <br />Tested Ma <br />Pass Fag <br />Not <br />Tested <br />Repairs <br />Made <br />Tank Annulars Cl 0 Exesn t from testing - <br />0 <br />0 <br />0 <br />0 <br />Continuously Monitored <br />Secondary Pipe 3 W 0, El El <br />0.0 <br />01 <br />0 <br />Piping Sum 1 W1 El El Ej <br />0 <br />0 <br />0 <br />0 <br />UDC n 0 D F -I <br />0 <br />0 <br />0 1 <br />0 <br />Fill Sump 0 0 0 0 <br />0 <br />0 <br />Spill Bucket 0 El 1 0 0 <br />0 <br />0 <br />0 <br />0 <br />if hydrostatic testing was performed, describe what was done with the water after completion of tests* <br />[I Placed In drums left on site for proper disposition. <br />Transported to next site for use in additional testing. <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 fall compliance iWh legal requirements <br />Technician's Signature: Date. 8/7/2015 <br />