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SWRCB, January 2002 <br />Page I of 7 <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 ownerloperatorfor submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />2. TESTING CONTRACTOR INFORMATION <br />3. SUMMARY OF TEST RESULTS <br />Component <br />Pass <br />Fail Not <br />Tested <br />Repairs Component <br />Made <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />Sat Dispenser #26 <br />Z <br />F-1 <br />0-77 <br />F-1 <br />❑R <br />-7 <br />0 <br />Main Dispenser #27 <br />Z <br />El <br />El <br />El <br />R <br />El <br />F-1 <br />Sat Dispenser #27 <br />Z <br />R <br />F-1 <br />El <br />F-1 <br />❑ <br />Ej <br />❑ <br />Main Dispenser #281 <br />❑1 <br />1:1 <br />Sat Dispenser #28 <br />Z <br />0I <br />El <br />FR -1 <br />Main Dispenser #29 <br />R <br />El <br />[Ell <br />Sat Dispenser #29 <br />z <br />= <br />-0 <br />El <br />Ej <br />F-1 <br />I Ej <br />Ej <br />Main Dispenser #30 <br />Z <br />R <br />El <br />El <br />9- <br />El <br />I R <br />El <br />Sat Dispenser #30 <br />ZIE] <br />R <br />1:1 <br />❑ <br />F-1 <br />I El <br />El <br />El <br />Ell <br />R <br />I El <br />El I El El El <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />n <br />I L]I <br />0 <br />1 1-1 <br />Test Water - Recycle and Reuse <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my knowledge, the facts stated in this document are accurate and in full compliance with legal requirements <br />Technician's Signature: 72Et-�,� 42w�c, Date 7/27/2011 <br />