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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 />FerTT.TTV TNFORMATTON <br />Facility Name: ARCO#2093 Date of Testing: 9/1/06 <br />Facility Address: 3425 Tracy Blvd., Tracy, CA 95376 <br />Facility Contact: Phone: <br />Date Local Agency Was Notified of Testing: SB989 — 3yr. Compliance Test/ Repair & Retest <br />Name of Local Agency Inspector (i(present during testing): <br />17 TFSTTNG CONTRACTOR INFORMATION <br />z SUMMARY OF TEST RESULTS <br />Component: <br />Pass <br />Fail Not <br />Tested <br />Repairs <br />Made <br />Notes: <br />Tank Annular - 4 <br />❑ <br />❑ X <br />❑ <br />❑ <br />❑ ❑ <br />❑ <br />Secondary Pipe - 5 <br />D <br />D 1 X <br />❑ <br />D <br />❑ ❑ <br />0 <br />Rjb�ineSump - 4 <br />❑ <br />❑ X <br />❑ <br />❑ <br />❑ ❑ <br />❑ <br />UDC - 4 <br />❑ <br />D X <br />❑ <br />❑ <br />❑ ❑ <br />D <br />Fill Sump - 4 <br />❑ <br />D X <br />❑ <br />❑ <br />❑ ❑ <br />❑ <br />TLM Sump - 0 <br />❑ <br />❑ X <br />❑ <br />❑ <br />❑ ❑ <br />❑ <br />Spill Bucket - 8 <br />X <br />❑ D <br />X <br />87#2 — fill bkt. & 91— vapor bkt. <br />❑ <br />❑ ❑ <br />❑ <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />***(No) — Drums left on site. <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 />Technician's Signature: <br />�e�Wn <br />Date: <br />