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SWRCB, January 1002 Page _ of _, SWRCB, January 2002 Secondary Containment Testing Report Form This form is urfended for rse by contractors performing periodic testing of UST secondan� ewdaimneal systems. Use the appropriate pages ojthu faro to report results for all components tested. The couplet d form, svniten testpwce dures, m:d printouts fi ora tern (ijpplrcable), should be provided to the jocilitr ---operator forsabteihal to the local regulato'y agency. 1. FACILITY INFORMATION Facility Name: Date of Testing: Facility Address: Facility Contact: Phone: Date Local Agency Was Notified of Testing Name of Local Agency Inspector tifpresent downig lestiog): 2. TESTING CONTRACTOR INFORMATION Company Name: Tank Manufacturer Othn (Spec f Technician Conducting Test: Industry Standard Credentials: CSLB Licensed Contractor SWRCB Licensed Tank Tester License ivpe: License Number: Manufacturer 31—farm— Training Com onent(s) Date Training Expires Hydrostatic Test Equipment Used: Equipment Resolution: b i -ora M .--_ lfhydrosmtic Iestiug was performed, describe what was done with thewater after completion of tests: CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING To the bestofW knowledge, the fhctastated in 916 do 11—t are accurate and hi f.0 contpilance midi legal reyuIrentena Technician's Page _ of_ TANK ANNU AR TESTING Test Method Developed By: Tank Manufacturer Othn (Spec f Industry Standard Professional Engineer Test Method Use d: Pressure Other (Sped) Vacuum Hydrostatic Test Equipment Used: Equipment Resolution: Tank # Tank # Taak # Tank # Is Tank Exempt From Testing?' Yes No Yes No Yes No Yes No Tank Capacity: Tank Material: Tank Manufacturer: Product. Stored: Walt time between applying pressareivacuumAvater and starting test: Test Start Time: Initial Reading Qin): Test End Time: Final Reading (Rr): Test Duration: Change in Reading (Rr-Rt): P—Tail Threshold or Criteria: TestResalt: Pass 'Fail Pass Fall Pass Fria Pass ' FaB Was sensor removed for testmg? Yes No NA Yea No NA 1'a No NA Yes No NA Was sensor properly replaced and verified functional after testing? Yes No NA Ya No NA Ya No NA 1'a No NA Comments — /include i formation on repairs oad, prior ro testing, and recourmended foll..... &jailed tests) ' Secondary containment systems where the continuous monitoring automatically monitors both the primary and secondary containment. such as systems that are hydrostatically monitored or under constant vacuum, are esempt from periodic containment testing. {Catffornia Code of Regulations, Title 23, Section 2637(aX6)) E