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SWRCB,January 2002 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 form to report resarlts for all components tested The completed form, written test procedures, and printouts from tests <br /> (if applicable), should be provided to the facility oit nerloperator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> i <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 . LLr <br /> i <br /> Name of Local Agency Inspector(if present during testing): <br /> h _ <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name:Belshire Environmental Services,Inc. r NMN Ej 1 <br /> Technician Conducting Test:Jeff Badders a,,�� �T�" <br /> Credentials: ® CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester <br /> License Type:A-General:Engineering Contractor License Number:808313 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> I <br /> I <br /> See Attached j <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> Tank Annulars 1 ❑ W W ❑ Exempt From Testing- ❑ ❑ ❑ ❑ <br /> Continuously Monitored <br /> Secondary Pie 3 W ❑ ❑ ❑ ❑ ❑ ❑ <br /> Piping Sump 1 ❑ W ❑ ❑ ❑ ❑ ❑ ❑ <br /> UDC ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Fill Sump ❑ W ❑ ❑ ❑ ❑ ❑ ❑ <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 of my knowledge,the facts stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: `�✓-��` �'�` ''''' Date: 8/2/2018 <br />