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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 />I F A (`TT .TTV TNF(IR M A TION <br />Facility Name: ARCO#2093 Date of Testing: 7/10/06 <br />Facility Address: 3425 Tracy Blvd., Tracy, CA 95376 <br />Facility Contact: Phone: 209 / 835-1665 <br />Date Local Agency Was Notified of Testing: SB989 — 3yr. Compliance Test / Repair <br />Name of Local Agency Inspector (fpresent during testing): <br />7_ TESTING CONTRACTOR INFORMATION <br />Manufacturer Training <br />Manufacturer Component(s) Date TrainingEx fires <br />Available upon request <br />1_ SUMMARY OF TEST RESULTS <br />Component: <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />Notes: <br />Tank Annular - 1 <br />X <br />❑ <br />❑ <br />X <br />87#2 - Passed <br />❑ <br />❑ <br />0 <br />❑ <br />Secondary Pipe - <br />0 <br />❑ <br />X <br />❑ <br />Turbine Sump - <br />❑ <br />❑ <br />X <br />❑ <br />❑ <br />.❑ <br />0 <br />❑ <br />UDC - <br />❑ <br />❑ <br />X <br />❑ <br />0 <br />❑ <br />❑ <br />❑ <br />®� <br />Fill Sump - <br />0 <br />❑ <br />X <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />TLM Sump - <br />❑ <br />❑ <br />X <br />❑ <br />❑ <br />0 <br />❑ <br />❑ <br />Spill Bucket - <br />0 <br />0 <br />X <br />0 <br />❑ <br />❑ <br />1 ❑ <br />❑ <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />CERTIFICATION OF TECIINICIAN 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: Date: <br />