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Secondary Containment Testing Report Form <br />This form is intended for use by contractors performing periodic testing of UST secondary containment systems, Use the <br />appropriate pages of this form to report results for all components tested. The completed form, written test procedures, and <br />printouts from tests (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1. FACTI.TTV IWORMATrnw <br />Facility Name: S 2 GUS Date of Testing: <br />Facility Address: c� $ �� ( s -f <br />Facility Contact: Phone: <br />Date Local Agency Was Notified of Testing: SB989 - <br />Name of Local Agency Inspector (if present during testing): <br />2. TESTING CONTR A CTOT? "-JT?ORM A TMV <br />Company Name: ABLE Maintenance, Inc. <br />Pass <br />Technician Conducting Test: jZ-et(_y 3U Plf <br />��u S'ti5 D �0 to -V \ <br />Credentials: ® CSLB Licensed Contractor <br />0 SWRCB Licensed Tank Tester <br />License Type: A, B, Haz., C10 <br />License Number: 312844 <br />Manufacturer <br />Manufacturer Trainin¢ <br />Component(s) Date Training Expires <br />Available upon request <br />0 <br />❑ <br />0 <br />1 <br />� <br />3. SUMMARY OF TEST RF,STII.Tlq <br />Component: <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />Notes: <br />Tank Annular - <br />❑ <br />0 <br />0 <br />0 <br />0 <br />❑ <br />0 <br />❑ <br />Secondary Pipe <br />❑ <br />❑ <br />❑ <br />0 <br />❑ <br />❑ <br />❑ <br />❑ <br />Turbine Sump - <br />❑ <br />❑ <br />❑ <br />0 <br />❑ <br />❑ <br />❑ <br />❑ <br />UDC - <br />❑ <br />❑ <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />Fill Sump - l u <br />9 <br />0 <br />0 <br />❑ <br />0 <br />0 <br />❑ <br />❑ <br />TLM Sump <br />❑ <br />❑ <br />❑ <br />❑ <br />Spill Bucket - <br />❑ <br />❑ <br />0 <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: 3rZ�j v <br />