Laserfiche WebLink
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 />7V Q'r IVn 7 - F A rTT .r'TV rNFORMA TTnN Page 1 of 1 <br />Facility Name: ARCO #2093 — Test No. 2 <br />Date of Testing: 5/1/06 <br />Facility Address: 3425 Tracy Blvd., Tracy, CA 95376 <br />Facility Contact: Phone: <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agency Inspector (rfpresent during testing): <br />FM Din I lorewerelov M.91-am1►1 • \/' a <br />4ZTTX4A4ARV nF TF.CT RF.CTTT.TC <br />Component <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 />Made <br />Annular Space—All grades <br />❑ <br />❑ <br />® <br />Fill Sum — 87#3 <br />El <br />0 <br />El <br />11 <br />Secondary Piping — 87-1 <br />0 <br />11 <br />Fill Sum — 91 <br />0 <br />0 <br />0 <br />11 <br />Secondary Piping — 87-2A <br />❑ <br />11 <br />© <br />0 <br />Fill & Vapor Buckets -87#1 <br />© <br />❑ <br />❑ <br />o <br />Secondary Piping — 87-213 <br />13 <br />0 <br />© <br />0 <br />Fill Bucket -87#2 <br />0 <br />o <br />10 <br />13 <br />Secondary Piping — 91 <br />D <br />❑ <br />El <br />❑ <br />Vapor Bucket -87#2 <br />El <br />0 <br />❑ <br />❑ <br />Sec. Piping— Syphon Line <br />11 <br />❑ <br />o <br />El <br />Fill & Vapor Buckets -87#3 <br />El <br />0 <br />❑ <br />El <br />STP Sum — 87#1 <br />0 <br />0 <br />11 <br />11 <br />Fill Bucket - 91 <br />El <br />❑ <br />0 <br />❑ <br />STP Sum — 87#2 <br />0 <br />0 <br />0 <br />1:1 <br />Vapor Bucket - 91 <br />0 <br />o <br />El <br />10 <br />STP Sum — 87#3 <br />® <br />11 <br />0 <br />11 <br />Dispense #1/2 <br />0 <br />0 <br />0 <br />10 <br />STP Sum - 91 <br />© <br />11 <br />o <br />11 <br />Dispense #3/4 <br />0 <br />❑ <br />0 <br />1:1 <br />Fill Sum — 87#1 <br />© <br />0 <br />O <br />11 <br />Dispenser #5/6 <br />0 <br />❑- <br />11 <br />❑ <br />Fill Sum — 87#2 <br />® <br />❑ <br />Dis enser 07/8 <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />CERTIFICATION OF I <br />To the best of my knowledge ghe facts <br />Technician's Signature: <br />4ICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />in this document are accurate and in full compliance with legal requirements <br />Date: :-, ` <br />