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4RECEIVED SWRCB, January 2002 S E P 0 8rYtW— o'— Secondary f_Secondary Containment Testing Report Form This form is intended for use by contractors performing periodic testing of UST secondary c L TH appropriate pages of this form to report results for all components tested. The completed form, writt '#nd printouts from tests (f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. 1. FACILITY INFORMATION 2. TESTING CONTRACTOR INFORMATION II)d F.11 t 1Mamam Component Pass Fail Not Tested Repairs Made Component Pass Fail Not Tested Repairs Made Annular Tank #1 X ❑ ❑ ❑ Secondary Pipe 48 X ❑ ❑ ❑ Annular Tank #2 X ❑ ❑ ❑ Secondary Pipe #9 X ❑ ❑ ❑ Annular Tank #3 X ❑ ❑ ❑ Secondary Pipe #10 X ❑ ❑ ❑ Annular Tank #4 X ❑ ❑ ❑ Secondary Pipe 411 X ❑ ❑ ❑ Annular Tank #5 X ❑ ❑ ❑ Secondary Pipe #12 X ❑ ❑ ❑ Secondary Pipe 41 X ❑ ❑ ❑ Piping Sump #1 X ❑ ❑ ❑ Secondary Pipe #2 X ❑ ❑ ❑ Piping Sump #2 X ❑ ❑ ❑ Secondary Pipe 43 X ❑ ❑ ❑ Piping Sump #3 X ❑ ❑ ❑ Secondary Pipe 44 X ❑ ❑ ❑ Piping Sump #4 X ❑ ❑ ❑ Secondary Pipe #5 X ❑ ❑ ❑ Piping Sump #5 X ❑ ❑ ❑ Secondary Pipe #6 X ❑ ❑ ❑ Vent Box Sump X ❑ ❑ ❑ Secondary Pipe #7 X ❑ ❑ ❑ Dispenser Sump #1&2 If hydrostatic testing was performed, describe what was done with the water after completion of tests: X ❑ ❑ ❑ Test Fluid Supplied and Recovered for reuse by, R&D Compliance Testing. CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING To the best of my knowledge, the facts stated in this document are accurate and in full compliance with legal requirements Technician's Signature: misa�� Date: August 11, 2014