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�SWRCB Januar 2002 • • Paof <br /> f � Y Page <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 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 /> 1. FACILITY INFORMATION <br /> Facility Name: Lawrence Livermore National Laboratory,Livermore Date of Testing:3/15/05 <br /> Facility Address: 7000 East Avenue,Livermore,Ca.94550 <br /> Facility Contact: Bi F-Srhv,a'rts SYuu+ tar t�,4or1 Phone: 925-423-66-216 '76o1oS` <br /> Date Local Agency Was Notified of Testing : 03/09/05 <br /> Name of Local Agency Inspector(ifpresent during testing): Robeft Sher, Su„ Jou <br /> vun'�y, <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Superior Underground Tank Service <br /> Technician Conducting Test: John W. Sutfm <br /> Credentials: X CSLB Licensed Contractor SWRCB Licensed Tank Tester <br /> License Type:A,B,Haz License Number:482356 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> OPW OPW Spill Buckets 2/17/06 <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> OPW Spill Bucket, DVER X UL 879-G3U1 Supply <br /> OPW Spill Bucket, PVER X <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowled ,the facts stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signa re: • �T-"%�—�J Dater �� <br />