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11 <br />SWRCB, January 2002 <br />Page 1 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 (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />FACILITY INFORMATION <br />2. TESTING CONTRACTOR INFORMATION <br />3. SUMMARY OF TEST RESULTS <br />Component <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />Component <br />Pass <br />Fail <br />NotRepairs <br />Tested <br />Made <br />UDC # 1-2 <br />UDC #20 Main <br />UDC # 3-4 <br />❑ <br />UDC #20 Satellite <br />FU <br />El <br />I ❑ <br />UDC # 5-6 <br />1 <br />❑❑ <br />❑ <br />UDC #21 Main <br />El® <br />❑ <br />El <br />UDC # 7-8 <br />❑ <br />UDC #21 Satellite <br />F-1UDC <br /># 9-10 <br />[:]UDC <br />#22 Main <br />®17 <br />❑ <br />UDC # 11-12 <br />[—]UDC <br />#22 Satellite <br />® <br />10 <br />UDC # 13 <br />❑ <br />❑ <br />UDC #23 Main <br />® <br />❑ <br />UDC # 14-15 <br />❑ <br />® <br />UDC #23Satellite <br />UDC # 16-17 <br />❑ <br />® <br />® <br />UDC #24 Main <br />® <br />❑ <br />❑ <br />❑ <br />UDC # 18 <br />❑ <br />UDC #24 Satellite <br />UDC # 19 Main <br />z <br />UDC 25 Main <br />UDC # 19 Satellite UDC #25 Satellite <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />Test water stored in (14) <br />55 Gallons drums and left on site for proper disposal. <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 11/30/2010 <br />