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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 <br /> appropriate pages of this form to report results for all components tested The completed farm,written test procedures, and <br /> printouts from tests(f applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Kaiser Permanente Hospital Date of Testing: 1-30-12 <br /> Facility Address: 7373 West Lane Stockton Ca <br /> Facility Contact: David Catanzmite Phone: 209-476- 0 <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(f present during testing): FE <br /> 2. TESTING CONTRACTOR]INFORMATION <br /> Company Name: JP Petroleum Service JOAQUIN COU <br /> EIRONS <br /> Technician Conducting Test: John Puumala <br /> AL <br /> Credentials: x CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester <br /> License Type: A License Number: 811471 ICC 4 5252406 <br /> Manufacturer Training <br /> Manufacturer Com anent s Date Training Expires <br /> 3. SUMMARY OF TEST RESULTS <br /> Not RepairsNot Repairs <br /> Tested Made <br /> Component Pass Fail Component Pass Fail Tested Made <br /> Annular 1 x El ❑ El ❑ El El <br /> Line 1 ❑ x ❑ ❑ ❑ ❑ 11 El <br /> Sump I ❑ x ❑ ❑ ❑ ❑ ❑ ❑ <br /> 0 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ 0 ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ 0 ❑ <br /> 0 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> Water was filtered and returned to holding tank. <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 /> Date: <br /> Technician's Sign e:` <br />