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• <br />s •RECEIVED <br />SEP 2 2 2016 <br />Secondary Containment Testing Report Form <br />This form it intended for use by contractors pertarming periodic testing of UST secondary containmeZ")j6q0➢.tMNTAL HEALTH <br />appropriate pages of thisf0m to report results for all components tested The completed form, written test prooKkPARWENT <br />printouts from tests (if applicable), should be provided to the facility owner/operator jar submittal to the local regulatory agency, <br />1. PAE`ir:1I-V t'lur,nnavA�tnrj <br />Facility Name:4 q <br />Facility Address: <br />k'i—"-N�.{-T —,,:�•-C.:�.J o\,L,Z, <br />Facility Contact: Phone; <br />1 Date Local Agency Was Notified of Testing : 4 I � SE999 -3 yr. Compliance. <br />i_ Name of Local Agency Inspector (if present during Ierrin) <br />2• TESTING COMTRAC"O?t RNF^rF2Jri54TfnN <br />Company Name: ABLE Maintenance, Inc. <br />Technician Conducting'fest: James Moore / I.C.C. #513"4517-Lrr <br />Credentials: 0 CS LB Licensed Contractor <br />p_S_WRCB Licensed Tank 1'ester <br />License Type: A, B, Haz., 60 <br />Manufacturer <br />Available upon request <br />License Number: 312844 <br />Manufacturer Trainint? r - <br />Component(s) Date Tminin Ex lires <br />G ❑ <br />❑ <br />❑ <br />G C <br />F3 <br />S?TPd MARY rte TWWr nrcrir'rc <br />Component:Pass <br />Fail Not <br />Tested <br />Repairs <br />Made <br />Notes; <br />Tank Annular -.I <br />G ❑ <br />❑ <br />❑ <br />G C <br />❑ <br />Secondary Pipe - <br />G ❑ <br />❑ <br />,�� <br />Turbine Sump - Z <br />❑ ❑ <br />❑ <br />❑ <br />❑ ❑ <br />❑ <br />UDC - 79 <br />❑ c <br />❑ <br />Fill Sump - '2— <br />G ❑ <br />❑ <br />-- <br />f_I ❑ <br />❑ <br />TLM Sump - <br />❑ <br />❑ ❑ <br />❑ <br />oT ='V <br />J <br />Ci ❑ <br />❑ <br />Spill Bucket - <br />❑ <br />❑ <br />t iz <br />a <br />❑ a <br />❑ <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <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: t--, 7-*, {'o <br />