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Secondary Containment Testing Report Form <br />For Use by Unidocs Member Agencies or where approved by your Local Jurisdiction <br />Authority Cited Health and Safety Code §25293, Title 23 CCR §2637(a)(4) <br />This form, or the standard form develped by the State Water Resources Control Board (S CB), must be used <br />by contractors performing periodic testing of underground storage tank (UST) secondary containment systems <br />in Unidocs member agency jurisdictions. The completed form, written test procedures, data collection logs, and <br />printouts from test equipment (if applicable), must be provided to the facility ownerloperator for submittal to <br />the local regulatory agency within 30 days of the test date. <br />SWRCB requires that the entire volume of each sump and under -dispenser containment (UDC) system be tested <br />if the sump is not equipped with a continuous monitoring system that shuts down the pump when a leak is <br />detecetd or the leak detection sensor fails or is disconnected. [see sWRCB Local Guidance Letter LG -1601 <br />Systems where leak detection equipment continuously monitors both primary and secondary containment (e.g. <br />systems that are hydrostatically monitored or under constant vacuum) are exempt from periodic testing <br />requirements. [23 CCR §2637(a)(6)] <br />In the case of pressure/vacuum testing, M loss in pressure/vacuum during the course of the test shall be <br />considered a failed test, regardless of the manufactureescriteria for declaring a passed test. (23 CCR §2637(a)(2)] <br />A. Facility Information <br />B. Testing Contractor Information <br />Company Name: YV) U p BdAL) Lu:e'-b 'E"a, 11w, <br />Credentials: [] CSLB-Licensed Contractor; [] SWRCB-Lice'Aed Tank Tester <br />License Type: E31A; [] C-10; E] C-34; [] C-36; C] C-61 (D40) License Number: <br />Name of Technician Conducting Tests: MANZ 9 Ou.; <br />Training !�y Equ!pment Manufacturer <br />Manufacturer I Component(s) Date Training Expires <br />C. Certiflication by Technicia sponsi for Conducting Testing <br />e <br />w <br />ao/ <br />To the best of my knowledge cts stated this document are accurate and in full compliance with <br />legal requirements. <br />Technician's Signature: V Date: <br />UN -054 -1/5 www.unidoes.org 02/26/02 <br />