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RECEIVED <br /> Secondary Containment Testing Report Form NOV 2 0 2017 <br /> Thu form is intended for use by contractors performing periodic testing of USTsecondary contain+��� /�,,�� <br /> appropriate pages ojthrs form to report results for all components tested The completed farm, wrtTMti' , o% E�EALTH <br /> printouts from tests(if applicable),should be provided to the facility owner/operator for submittal to the loc n <br /> I' FACILITY INFORMATION <br /> Facility Nam <br /> \Z' Date ofTesting:zev %W]6 <br /> Facility Address: Ie, �. �.r = � - ��.U�\_�a �5�6 <br /> Facility Contact: _ khon <br /> e; ---- <br /> 67 <br /> Date Local Agency Was Notified of Testing: I. � S ole: --3 yr.Compliance <br /> Name of Local Agency lnspector(ifpresent d+minim test»tt;): - <br /> 98 <br /> 2' T`3?IN!®CONTRACTOR INFORMATION <br /> Company Name:ABLE Maintenance,Inc. au�„ <br /> Technician Conducting Test: James Moore/l.C.C.,52545 77-UT <br /> Credentials: 0 CSLB Licensed Contractor C SWRCB Licensed Tank Tester <br /> License Type:A, E,Hoz.,CIO License Number: 3I2S44 <br /> MannfacturerTram .ins <br /> Manufacturer Com Doan s) Date <br /> Available upon ues[ Trainin Ex fres <br /> 3. SUMMARY OF TEST RESULTS <br /> Component: Pass <br /> Fail Not Repairs } <br /> Tested Mado Nota: I. <br /> Tani:Annular - I ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> Secondary Pipe - t ❑ ❑ ❑ <br /> Turbine Sump - 'L ❑ ❑ ❑ <br /> unc - Y) `Ll ❑ ❑ — <br /> n ❑ ❑ ❑ <br /> Fill Sump - ❑ ❑ ❑ <br /> ❑ ❑ o ❑ — <br /> TLM sum - ❑ ❑ ❑ ❑ <br /> a ❑ o ❑ <br /> Spill Bueket - r# - ❑ - <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tesis: <br /> ��Y� 'mac �Lir'�.-• <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> 710 the best ojmy knowledge, a facia stated in Uric document are accurate and!n full compliance with legal requirements <br /> Technician's Signator': Uate:_ {�+ +'Z�• `,b <br />