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R E CIE-,�9 W E D <br /> JAN 2 4 2007 . <br /> j Secondary Containment Testing Report Form <br /> ENVIRO ' ENT HEALTH <br /> This form is intended for use by contractors performing periodic testing of UST secondary containment sys � ,�YJCES <br /> appropriate pages of this form to report results for all components tested The completedform, written tes proced r �a <br /> printouts from tests (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: ARCO# Date of Testing: <br /> Facility Address: �f/ t✓ <br /> F cs lity Contact: Phone: <br /> Date Local Agency Was Notified of Testing: - SB989—3yr.Compliance Test <br /> Name of Local Agency Inspector(if present during testing): <br /> 2, TESTING CONTRACTOR INFORMATION <br /> Company Name: ABLE Maintenance, Inc. <br /> Technician Conducting Test: James Moore/I.C.C.#5254517-UT <br /> Credentials: ® CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester <br /> License Type: A, B, Haz.,CIO License Number: 312844 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> Available upon request <br /> 3, SUMMARY OF TEST RESULTS <br /> Component: Pass Fail Not Repairs Notes:Tested Made <br /> Tank Annular - zI- ❑ ❑ ❑ <br /> 0 ❑ ❑ ❑ <br /> Secondary Pipe - ❑ ❑ ❑ <br /> ❑ ❑ 0 ❑ <br /> Turbine Sump ❑ ❑ ❑ <br /> UDC - IA— ❑ 0 0 <br /> Fill Sump - ❑ ❑ ❑ <br /> TLM Sump - ❑ ❑ ❑ <br /> Spill Bucket - El ❑ ❑ <br /> El El <br /> 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 larowlerI e, tl,e facts stated in this document are accurate and in full compliance with legal requirements <br /> Date: <br /> Technician's Signature: <br /> e <br />