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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 form,written test procedures, and <br /> printouts from tests(if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Tracy Unified School Dist Date of Testing: 12/16/05 <br /> Facility Address: 1975 W.Lowell Avenue Tracy,Ca 95376 -a <br /> PIR <br /> Facility Contact: John Heerema Phone: 209-831-5051 <br /> Date Local Agency Was Notified of Testing: 12/1/05 <br /> Name of Local Agency Inspector(if present during testing): none <br /> 2. TESTING CONTRACTOR INFORMATION �IVIRaJ�ENT N S <br /> Company Name: JP Petroleum Service <br /> Technician Conducting Test: John Puumala 6q 16 — 40 S <br /> Credentials: x CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester <br /> License Type: A I License Number: 811471 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <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 Diesel x I ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Annular 2 Regular x ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Line 1 Diesel main x ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Line 2 Regular main x ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Line 3 Regular x ❑ I ❑ ❑ ❑ 1 ❑ ❑ 1 ❑ <br /> Line 4 Diesel x ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Sump 1 Diesel x ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Sump 2 Regular x ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> UDC 1&2 x ❑ ❑ ❑ ❑ ❑ AE01 <br /> UDC 3&4 x ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ <br /> El ❑ 11El ❑ 11 <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 nt are accurate and in full compliance with legal requirements <br /> --- <br /> Technician's Signa Date: <br />