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SWRCB, January 2002 • FINAL DRAFT • Secondary Containment Testing Report Form Page I of 7 Pages 5, 6,7�f 7 Ndf -Tn d vdej 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, written test procedures, and printouts from tests (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. 1. FACILITY INFORMATION Facility Name: Lawrence Livermore National laboratory Site 300 882 - DI U I Date of Testing: 12-28-2065' 02l Facility Address: Corral Hollow Road, Tracy, CA 95376 Facility Contact: Shari Brigdon Phone: (925) 423-7665 Date Local Agency was Notified of Testing: 12 -23 -200?, -1= Name of Local Agency Inspector (if present during testing): 2. TESTING CONTRACTOR INFORMATION Company Name: Thornton Environmental Construction, Inc. FET M-5 Technician Conducting Test: Brian Thornton 0 STU V "Ma Credentials: ® CSLB Licensed Contractor ❑ SWRCB Licensed Tank Tester License Type: A, C-10, HAZ 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 3. SUMMARY OF TEST RESULTS 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 OF 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: Date: 12-29-20W &Af 00�=: FET M-5 ff UTP "M 0 STU V "Ma "fA 01' • /�/ U�70 UU��L� u�uo r�r�ur:� uuvo wu uuuo oo�u uuuu �uuu u�uo �uuu uo�o ou�u' 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 OF 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: Date: 12-29-20W &Af