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06/05/2003 08:35 77535 .1 LA PERKS PAGE 08 <br />Page 1 of 2 <br />Secondary Containment 'Vesting Report Form <br />Ms form is intended for use by contractorsperforming periodic testing of U,ST ovcondary containment sygems. IIse the appropriate <br />pages of this fort to report results for all components tested The completed form, written test procedures, and printouts jsnm tests (if <br />applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />3. SUMMARY OF TEST RESULTS <br />Number of Tanks Tested: 0 Number of Piping Runs Tested -0 <br />Number of Submersible Pump Sumps Tested:0 -Number of UDC Boxes Tested:0 <br />Number of Fill Sumps Tested:0 Number of Overfill Boxes Tested:x <br />Component Pass <br />Fail I Comments <br />87 fill X <br />❑ <br />91 fill ❑ <br />X Fill needs drain replaced <br />O <br />❑ <br />❑ <br />❑ <br />o <br />❑ <br />❑ <br />❑ <br />4 <br />❑ <br />O <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />o <br />M <br />❑ <br />❑ <br />C7 <br />Technician's <br />Date: 5/19M <br />