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Secon Containment Testing RepWorm <br />This form is intended for use by contractors performing periodic testing of UST secondary con ainment systems. Use the appropriate pages of <br />this form to report results for all components tested. The completed form, written test procedures, and printouts from tests (if applicable), <br />should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />I. FACILITY INFORMATION CLLC: TRACCAII GEO PAR: UE -058 <br />Facility Name: SBC I Date of Testing: 8/5/04 <br />Facility Address: 10 E. 12TH STREET TRACY, CA <br />Facility Contact: KATHY HALLIGAN Phone: 209-474-4514 <br />Date Local Agency Was Notified of Testing: 48 HOURS PRIOR <br />Name of Local Agency Inspector (fpresent during testing): <br />2. TESTING CONTRACTOR INFORMATION <br />3. SUMMARY OF TEST RESULTS <br />Not Repairs Component Pass Fail Not Repairs <br />Component Pass Fail Tested Made p Tested Made <br />DIESEL FILL <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <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 <br />requirements <br />Technician's Signature: "�' ��'Date: 8/5/04 <br />