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09/22/05 11:02 FAX 925 422 2748 EPD / WGMG 0 002 <br /> s <br /> SWRC ,January 2002 FINAL DRAFT Pagc 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(ffapplicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACELYIPY INFORMATION <br /> Facility Name: Lawrence Livermore National Laboratory Site 300 Date of Testing: 8-'29-2005 <br /> Facility Address: Corral Hollow Road,Tracy,CA 95376 1Bldg. 882_ <br /> Facility Contact: Shari Brigdon Phone: (925)423-7665 _ <br /> Date Local Agency was Notified of Testing: 841-2005 <br /> Name of Local Agency Inspector(if present during testing): No Local Agency Inspector present. <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Thornton Environmental Construction,Inc. <br /> Technician Conducting Test: Brian Thornton <br /> Credentials: ® CSLB Licensed Contractor ❑ SWRCB Licensed Tank Tester <br /> License Type:A,C-10,HAZ License Number:724513 <br /> o: ,:. ::,:u,>.,f umc�•:•a.:xx n:.,e.. ..w, .,a v-y: s, .:..tM1.- ,.:....,rsr,. ,...:e ,..:,i.r::— <br /> anufacturer Training <br /> Manufacturer Component Date Training Expires <br /> Veeder-Root Leak Monitor 01-22-2007 <br /> Ronan Leak Monitor 12-13-2005 <br /> PTSD Leak Alert Leal,ATonitor 11-01-2005 --- <br /> Caldwell Sump Level Change Indicator One time training <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> 882-DIU2 TANK ANNULAR ❑ -- <br /> 882-DIU2 PIPING SUMP ❑ El <br /> 882-D1U2 FOS/FOR CONT.PIl'E <br /> ❑ ❑ <br /> El <br /> ❑ - <br /> [:] <br /> tR <br /> ❑ <br /> Comments—If hydrostatic testing was performed,describe what was done with the water after completion of test(s). <br /> Test water was lett on site in rm tomers 45 aallr!n DOT linimc for disnosal by 11-VI,Hazardmis Waste Manage e—rt. <br /> CERTIFICATION OF TECIINICLILN 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 Name(Please Print): Brian Thornt <br /> Technician's Signature: r--- Date:8-29-2005 <br />