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SWRCB,January 2002 Page of <br /> Secondary Containment Testing Report Form <br /> This form is intended for use by contractors per forming periodic testing of U,ST secondary contaimiteitt systems. Use the appropriate <br /> pages of this form to report results for all components tested. The completed forn►, mwtten test procedures, and printouts from tests <br /> (if applicable), should be provided to the facilityotinnei/operator for submittal to the local regulator:y agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Kaiser Manteca Date of Testing:8/2/2018 <br /> Facility Address: 1777 W.YOSEMITE AVENUE,MANTECA,CA 95337 <br /> Facility Contact: Kaiser Permanente-North Phone: <br /> Date Local Agency Was Notified of Testing: 6/18/2018 10 1AMW <br /> Name of Local Agency Inspector(if present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name:Belshu•e Environmental Services,Inc. <br /> NTAL HEAL <br /> Technician Conducting Test:Jeff Badders <br /> Credentials: ® CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester <br /> License Type:A-General Engineering ContractorLicense Number:808313 <br /> ME <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> i <br /> See Attached <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not RepairsNotPass Fail Nat Repairs <br /> Tested Made Tested Made <br /> Tank Annulars 1 ❑ ❑ [] ❑ Exemiot From Testing- ❑ ❑ ❑ ❑ <br /> Continuously Monitored <br /> Secondary Pie 3 0 ❑ ❑ E ❑ ❑ ❑ ❑ <br /> Piping Sum 1 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> UDC ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Fill Sump ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Spill Bucket ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> 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 ofmy knowledge,the facts stated in this document are accurate and in frill compliance with legal requirements <br /> Teclmician's Signature: (.�✓-�� Date: 8/2/2018 <br />