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. l <br /> Y <br /> Secondary Containment Testing Report Form Ott <br /> For Use by Unidocs Member Agencies or where approved by your Local Jurisdiction Y <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 (SWRCB), 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 owner/operator 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/UDC 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 Lca 60] <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, a_y loss in pressure/vacuum during the course of the test shall be <br /> considered a failed test,regardless of the manufacturer's criteria for declaring a passed test. [23 CCR§2637(ax2)] <br /> A. Facility Information <br /> Facility Name: AI s0 �l 7�l) C E^►7'Li2 Date of Testing: Cvs t _4V AQ12 <br /> - <br /> Site Address: t c:L_ C: t.�t F N C <br /> Facility Contact: ,� /Vl Phone: 7ol t E <br /> Date Local Agency was Notified of Testing <br /> Name of Local Agency Inspector(f present during testing): <br /> B. Testing Contractor Information <br /> Company Name: 4-e <br /> Credentials: CSLB-Licensed Contractor; ❑SWRCB-Licensed Tank Tester <br /> License Type: ❑A;❑C-10;❑C-34;❑C-36;2C-61 (D40) License Number: 7 <br /> Name of Technician Conducting Tests: ,Q(> 't /C C Q tfaa oZ <br /> Training by Equipment Manufacturer <br /> Manufacturer Component(s) Date Training Expires <br /> to VR Z .E 1 cA Sp&jt AtWma i 2/ .xu i <br /> C. Certification by Technician Responsible for Conducting Testing <br /> To the best of my knowledge,the facts stated in this document are accurate and in full compliance with <br /> legal requirements. <br /> Technician's Signature: Date: <br /> UN-054-115 www.unidoes.org 02/26/02 <br />