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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. FACTT.TTV TN nnMATTrir-r 11V1\ Facility Name: Date of Testing: Facility Address: 1 q &-7 _ R,, 5 I -Ca Facility Contact: Phone: Date Local Agency Was Notified of Testing : SB989 - Name of Local Agency Inspector (if present during testing): 2. TESTING CONTRACTOR INFORMATION Company Name: ABLE Maintenance, Inc. Pass j Technician Conducting Test: Not Tested Credentials: ® CSLB Licensed Contractor ❑ SWRCB Licensed Tank Tester License Type: A, B, Haz., C1 D License Number: 312844 Manufacturer Manufacturer Training -Component(s)Date Training Expires Available upon request ❑ A 12, 3. SUMMARY OF TEST RESULTS Component: Pass Fail Not Tested Repairs Made Notes. Tank Annular - ❑ ❑ 1 ❑ ❑ 12, ❑ 1 0 0 Secondary Pipe - ❑ ❑ ❑ ❑ 0 0 0 0 Turbine Sump - UDC - 0 0 ❑ ❑ 0 0 0 0 ❑ ❑ i 0 0 0 0 ❑ Fill Sump - ) 0 0 0 el 0 0 0 0 TLM Sump - ❑ ❑ ❑ ❑ 0 ❑ 0 Spill Bucket - 0 ❑ 1 0 0 0 0 0 ❑ If hydrostatic testing was performed, describe what was done with the water after completion of tests: CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING To the best of my knowledge, the facts stated in this document are accurate and In full compliance with legal requirements Technician's Signature: �� Date: 'i