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.01/28/05 16:13 FAX 925 422 2748 EPD / WGMG 1j003 SWRCB, January 2002 FINAL DRAIFT Page I of Secondary Containment Testing Report Form This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the appropriate pages of this form to report results for all components tested. The completed form, mitten test procedures, and printouts from tests (if applicable), should be provided to the facility ownerloperatorfor submittal to the local regulatory agency. 1. FACILITY INFORMATION Facility Name: Lawrence Livermore National Laboratory Site 300 882 -Dr 1A 1] Date of Testing: 12-28-2005"o// -Facility Address: Corral Hollow Road, Tracy, CA 95376 - -Facility Contact: Shari Brigdon - - I Phone: (925) 423-7465 -Date Local Agency was Notified of Testing: 12-23-20DTt,,>+ Name of Local Agency Inspector (if present during testing): Name: Thornton Environmental Construction, Inc. -Company Technician Conducting Test: Brian Thornton Credentials: 0 CSLB Licensed Contractor E] SWRCB Licensed Tank Tester License Type: A, C-10; HAZ 7 License Number: 724513 Manufacturer Manufacturer Training Component Date Training Expires Veeder-Root Leak Monitor 06-10-2005 Ronan Leak Monitor 12-13-2005 USD Leak Alert Leak Monitor 11-01-2005 Caldwell Sump Level Change Indicator. One time training Comments - If hydrostatic testing was performed, describe what was done with the water after completion of test(s). -Test water was left on site in customers 55 gallon DOT drums for disposal by customer. CERTIFICATION 05 TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING To the best of my knowledge, the facts stated in this document are accurate and in full compliance with legal requirements. Technician's Name (Please Print): Brian Thornton Technician's Signature: _Z2 Date: 12-29-201" Component Em NMI DIESEL TANK ANNULAR IL DIESEL PIPING SUMP F*S/ FOR CONTAINMEN "M MEN 0E MOM E Comments - If hydrostatic testing was performed, describe what was done with the water after completion of test(s). -Test water was left on site in customers 55 gallon DOT drums for disposal by customer. CERTIFICATION 05 TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING To the best of my knowledge, the facts stated in this document are accurate and in full compliance with legal requirements. Technician's Name (Please Print): Brian Thornton Technician's Signature: _Z2 Date: 12-29-201"