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v <br />SWRCB, January 2002 <br />Page _ I _ of —I— <br />Secondary <br />I <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 owner/operator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION CLLC: TRACCA11 GEO PAR: UE -058 <br />2. TESTING CONTRACTOR INFORMATION <br />Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br />Tested Made Tested Made <br />ANNULAR <br />SUPPLY SECONDARY PIPING <br />RETURN SECONDARY PIPING <br />VENT SECONDARY PIPING <br />PIPING SUMP <br />FILL SUMP <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />*All Hydrostatic Test fluid was re -contained in (1) 55 gallon poly drums. <br />All drums are labeled non-haz and are ready for transport. <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: Date: -8/17/06 <br />