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0 ,14e PL i <br /> SWRCB,January 2002 � o <br /> Secondary Containment Testing Report Form MAR <br /> R 0 <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 resultsfor all components tested The completedform, written test <br /> printouts from tests(if applicable),should be provided to the facility ownerloperatorfor submittal to the <br /> 1. FACILITY INFORMATION --f—Date of Testing: 1-30-13 <br /> Facility Name: Kaiser Permanente Hospital <br /> Facility Address: 7373 West Lane Stockton Ca <br /> Facility Contact: David Catanzarite Phone: 209-476-5408 <br /> Date Local Agency Was Notified of Testing: I <br /> Name of Local Agency Inspector(ii(present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: JP Petroleum Service <br /> Technician Conducting Test: John Puumala <br /> Credentials: x CSLB Licensed Contractor 0 SWRCB Licensed Tank Tester <br /> License Type: A License Number: 811471 ICC#5252406 <br /> Manufacturer Training <br /> Manufacturer Com ponent(s) Date Training E?;pfres <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> Annular I x 0 0 0 0 0 0 0 <br /> Line 1 0 x 0 0 0 0 0 0 <br /> Sump 1 0 x 0 0 0 11 1 0 0 <br /> 0 0 El El D El El El <br /> El 0 [1 0 El 0 El 11 <br /> 0 D El 1:1 0 El D11 <br /> El El 1 11 El 11 [1 El±E1 <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 Signa <br />