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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 resultsfor all componenu 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. 1. FACILITY INFORMATION FacilityName: Date of Testing: 7 1/54//a Facility Address: g & } — , K to Facility Contact: Phone: Date Local Agency Was Notified of Testing: SB989 - Name of Local Agency Inspector (ifpresent during testing): 2. TESTING CONTRACTOR iNFnRMATrnN Company Name: ABLE Maintenance, Inc. Pass Technician Conducting Test: t� �.-� --:5 C,X,9�-t,Zc�•s-5 Credentials: ® CSLB Licensed Contractor ❑ SWRCB Licensed Tank Tester License Type: A, B, Haz., C10 License Number: 312844 Manufacturer Manufacturer Trainin¢ Component(s) Date Training Expires Available upon request 3. SUMMARY OF TEST RESULTS Component: Pass Fail Not RepairsTested Made Notes: Tank Annular - p !� ❑ ❑ 0 Secondary Pipe - (p 1, ❑ ❑ ❑ ❑ ❑ 0 0 Turbine Sump - ❑ ❑ ❑ UDC - ❑ ❑ ❑ ❑ ❑ ❑ ❑ 0 Fill Sump - ❑ ❑ ❑ ❑ TLM Sump - ❑ ❑ ❑ ❑ Spill Bucket - ❑ ❑ ❑ ❑ 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 l