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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 results for all components tested. The completed form, »>ritten test procedures, and printoutsfrom tests <br /> (i f applicable), should be provided to the facility omier/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Kaiser Stockton I Date of Testing: 12/6/2017 <br /> Facility Address: 7373 WEST LANE,STOCKTON,CA 95210 <br /> Facility, Contact: Kaiser Permanente-North Phone: <br /> Date Local Agency Was Notified of Testing: 11/9/2017 <br /> Name of Local Agency Inspector(if present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name:Belshire Environmental Services,Inc. <br /> Technician Conducting Test:Jeff Badders <br /> Credentials: S 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 /> See Attached <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 © O O ❑ ❑ ❑ ❑ ❑ <br /> Secondary Pie 2 © ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Piping Sump 1 ❑ ❑p ❑ ❑ ❑ ❑ ❑ ❑ <br /> UDC ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Fill Sump ❑ ❑ ❑ ❑ ❑ 1 ❑ <br /> Spill BucketO O ❑ ❑ ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> 0 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 fads stated in this document are accurate and iu full compliance Yvith legal requirements <br /> Technician's Signature: ( �f ' '"`""�```'" Date: 12/6/2017 <br />