HomeMy WebLinkAboutSB989 2015SWRCB, January 2002 Page ____ of ____
Secondary Containment Testing Report Form
This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the
appropriate pages of this form to report results for all components tested. The completed form, written test procedures, and
printouts from tests (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency.
1. FACILITY INFORMATION
Facility Name:Date of Testing:
Facility Address:
Facility Contact:Phone:
Date Local Agency Was Notified of Testing :
Name of Local Agency Inspector (if present during testing):
2. TESTING CONTRACTOR INFORMATION
Company Name:
Technician Conducting Test:
Credentials:
SWRCB, January 2002 Page ____ of ____
4. TANK ANNULAR TESTING
Test Method Developed By:
SWRCB, January 2002 Page ____ of ____
5. SECONDARY PIPE TESTING
Test Method Developed By:
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6. PIPING SUMP TESTING
Test Method Developed By:
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7. UNDER-DISPENSER CONTAINMENT (UDC) TESTING
Test Method Developed By:
SWRCB, January 2002 Page ____ of ____
8. FILL RISER CONTAINMENT SUMP TESTING
Facility is Not Equipped With Fill Riser Containment Sumps
SWRCB, January 2002 Page ____ of ____
9. SPILL/OVERFILL CONTAINMENT BOXES
Facility is Not Equipped With Spill/Overfill Containment Boxes