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HEGEIVEL� <br /> MAR 0 7 2016 <br /> Secondary Containment Testing Report Form ENVIRONMENTAL <br /> This form is intended for use by contractors performing periodic testing of UST secondary containment systetit'.7"`l'I eW'er-0A-0TA Pr_-h. r <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 he provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Named,-,_Z., 9 ci�h Date of Testing: 2- <br /> Facility Address:',J7 4 W4 Gh 5 L v1m <br /> Facility Contact: Phone. <br /> Date Local Agency Was Notified of Testing: SB989 <br /> Name of Local Agency Inspector(ifpresent during testing): <br /> 2. TESTING CONTRACTOR LNI FORMATION <br /> Com any Name:ABLE Maintenance,Inc. <br /> Technician Conducting Test: S <br /> Credentials: ® CSLB Licensed Contractor D SWRCB Licensed Tank Tester <br /> License Type:A,B,Hm,C10 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. PHAA Fail Not RepairsTested Madc Notes. <br /> Tank Annular - ❑ ^ <br /> C :1 Cl <br /> Secondary Pipe - ❑ ❑ <br /> C C U C <br /> Turbine Sump <br /> UDC - .1 ❑ ❑ El <br /> ❑ C C G <br /> Fill Sump - ( ❑ 71 ❑ <br /> C C C 5 <br /> TLM Sump - ❑ g — <br /> C ❑ ' ❑ ❑ <br /> Spill Bucket - ❑ p ❑ u <br /> 0 C rl ^ <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 fact•stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Sign; te: .�— Date-156-015 1 t/ <br />