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1 <br /> RECEIVED <br /> NOV 14 2014 <br /> ENVIRONMENTAL HEALTH <br /> Secondary Containment Testing Report Form D17PARTMENT <br /> This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the <br /> appropriate pages of thisforin to report results for all components tested. The compleredform, written test procedures, and <br /> printouts front tests(if applicable),should be provided to the facility ownerJoperator for submittal to the local regulatory agency. <br /> 1. .FACILITY INFORMATION <br /> Facility Name: z:�'V IPS-'T" 'T�C,� e. Date of Testing:h /lot 14 <br /> Facility Addirs+s: <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing SB989—3 yr.Compliance <br /> Name of Local Agency Inspector(rfpreseni during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name:ABLE Maintenance,Inc. <br /> Technician Conducting Test: James Moore/I.C.C.#5254517-tJT <br /> Credentials: ($I CSLB Licensed Contractor 0 SWRCI3 Licensed Tanis Tester <br /> License Type:A,B,Haz.,CIO License Number; 312844 <br /> ���'S�:mi7YC.7ticII�JZ did ��d "�78.'L-'±Z9u'i[lu �ZT•LGSa3t u• rsNow V. <br /> Manufacturer Training <br /> Manufacturer Com anent s Date Tlrainin be ires <br /> Available upon request <br /> 3. SUMMARY OF TEST RESULTS <br /> Component; Paso Fail Not Repairs Notes: <br /> Tested Made <br /> Tank Annular - '2 D 0 0 <br /> ❑ D D D <br /> Secondary Pipe -"� D G ❑ <br /> ❑ ❑ D D <br /> Turbine Sump - ''� D D ❑ <br /> a D D ❑ <br /> UDC - i D 0 D <br /> Fill Sump - �' ❑ ❑ D <br /> Q ❑ D ❑ <br /> T-LM Sump - 0 ❑ D 0 <br /> 0 J D Q <br /> Spill Bucket -1,o 0 0 D �cQ <br /> D 0 0 0 <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 Signahueyr <br />