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SWRCB.Ianuarv2002 %%W v 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 thisform 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 factlity owner/operator for submittal to the local regulatory agency. <br />r <br />1. FACILITY INFORMATION <br />s. <br />C <br />w <br />6. <br />b. <br />%W <br />Facility Name: y J f£Ic h Date of Testing: <br />Facility Address: 1 3 5 E. 1'`jGtld e ro <br />Facility Contact: Phone: (ZD9 q 3 3 - i 30 <br />Date Local Agency Was Notified of Testing 12oog <br />Name of Local Agency Inspector (ifpresent during testing): STEVEN C. SHIN <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: ATOM ENVIRONMENTAL CONTRACTING, INC. <br />Technician Conducting Test: MARK E. SWEET <br />Credentials: X CSLB Licensed Contractor X SWRCB Licensed Tank Tester <br />License Type: A-831863 W/ HAZ License Number: SWRB 02-1631 <br />Manufacturer Trainin¢ <br />Manufacturer Conr nent(s) Date Training Expires <br />INCON STS SUMP TESTER 7/9/2005 <br />ESTABROOK TANK TEST EQUIPMENT 12/31/2005 <br />3. SUMMARY OF TEST RESULTS <br />Component <br />P <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />Component <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />I Made <br />GEAR ANNULAR <br />X <br />❑ <br />❑ <br />❑ <br />ANTIFRZE PIPING SUMP <br />❑ <br />\ <br />❑ <br />❑ <br />MOTOR OIL ANNULAR <br />X <br />❑ <br />❑ <br />❑ <br />GEAR PIPING SUMP <br />❑ <br />X <br />❑ <br />❑ <br />USED OIL ANNULAR <br />X <br />❑ <br />❑ <br />❑ <br />MOTOR PIPING SUMP <br />❑ <br />X <br />❑ <br />❑ <br />ANTIFREEZE ANNULAR WET <br />❑ <br />X <br />❑ <br />USED OIL PIPING SUMP <br />❑ <br />X <br />❑ <br />❑ <br />SOAP ANNULAR WET <br />❑ <br />X <br />❑ <br />SOAP PIPING SUMP <br />X <br />❑ <br />❑ <br />❑ <br />SLOP (1) ANNULAR WET <br />❑ <br />X <br />❑ <br />SLOP (1) PIPING SUMP <br />❑ <br />X <br />❑ <br />❑ <br />SLOP (2) ANNULAR WET <br />❑ <br />X <br />❑ <br />SLOP (2) PIPING SUMP <br />❑ <br />X <br />❑ <br />❑ <br />ANTI FRZE SECONDARY LINE <br />X <br />❑ <br />❑ <br />❑ <br />ALL 5 GA CONTAINMENT <br />❑ <br />❑ <br />X <br />❑ <br />GEAR OIL SECONDARY LINE <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />MOTOR OIL SECONDARY LINE <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />SOAP SECONDARY LINE <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />GRAVITY LINES(USED <br />OIL.SLOP 1&2) <br />❑ <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />If hydrostatic testing a as performed. describe a hat ryas done a idi the nater after completion of tests: <br />PUMPED OUT INTO CLARAFIER <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the hest of my know{edge, the fads stated in ument are accurate and in full compliance with legal requireurents <br />^U��./,I <br />Technician's Signature: ' / ' L Date: / / =z c:'t <br />