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RECEIVED <br />SWRCB, January 2002 Page of <br />Secondary Containment Testing Report Form DEC 06 .2013 <br />This form is intended for use by contractors performing periodic testing of UST secondary containmentEWIRONMENTAL <br />appropriate pages of this form to report results for all components tested. The completed form, written testF A)ER HTMENfT <br />printouts from tests (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency, <br />FACII_,ITY INFORMATION <br />G. 11,!)111VliUU1NIKAUFORINFORMATION <br />3. SUMMARY OF TEST RESULTS <br />Component <br />A <br />Pass <br />Fail Not <br />1'esked <br />Repairs <br />Made Cmm��m�ocnt <br />Pass <br />Nmt <br />Repairs <br />ritade <br />Annular Tank <br />❑ <br />❑ X <br />❑ <br />�jtd <br />❑ <br />Secondary Pipe <br />X <br />❑ ❑ <br />❑ <br />F - <br />Piping Sump <br />❑ <br />X ❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Dispenser Sump <br />X <br />❑ © <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ ❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ ❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ ❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ ❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Ci <br />❑ <br />❑ ❑ <br />Q <br />❑ <br />❑ <br />❑ 1 <br />❑ <br />j <br />❑ Cl <br />11❑ <br />El <br />El <br />Ll <br />❑ <br />❑ ❑ <br />❑ <br />Q <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ ❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />If hydrostatic testing was performed, describe <br />what was done <br />with the water after completion of tests: <br />Test Fluid Supplied and recovered for reuse by, R&D Compliance Testing. <br />See comments page #2 and Page #4. <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my knowledge, the facts staled in this document are accurate and in full compliance with legal requirements <br />Technician's Signature: Date: September 24, 2013 <br />