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JAN 0 3 20 16 <br /> ENVIHONMENT,.A <br /> Secondary Containment 'Testing Report Form �Ir—AITu nr:D'3QTaV7A1T <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. FACILITY INFORMATION <br /> 7Local <br /> : - Date of Testing: 12 �/15 <br /> ss: ��'t `k` �� � <br /> Coct: Phone: <br /> ency Was Notified of Testing : , SB989-3 yr. Compliance <br /> l Agency Inspector(if present during resting): <br /> 2, TESTING CONTRACTOR INFORMATION <br /> Company Name:ABLE Maintenance,Inc. <br /> Technician Conducting Test: James Moore/I.C.C.#5254517-UT <br /> Credentials: ® CSLB Licensed Contractor C SWRCB Licensed Tank Tester <br /> License Type:A,B, Haz,C10 License Number: 312844 <br /> �_.�-.ar •�sir-=r.�;r:._ _ ' - - - - <br /> Manufacturer Training <br /> Manufacturer Com onent(s) Date Training Expires <br /> Available upon request _ <br /> i <br /> 3, SUMMARY OF TEST RESULTS <br /> Not Repairs Notes: <br /> Component: Pass Fail Tested Made . <br /> Tank Annular - ❑ 01 ❑ <br /> D ❑ C ❑ I �_ <br /> Secondary Pipe <br /> U D D v <br /> Turbine Sump - 1 •� �To-' TV" � �I <br /> UDC <br /> P - D D ❑ <br /> D D ❑ ❑ d <br /> Fill Sump - D ❑ G <br /> 0 ❑ C ❑ <br /> TLM Sump - ❑ ❑ ��P� <br /> rSpilElBueEket �- 4- <br /> G ❑ ❑ ��- <br /> n ❑ ❑ c <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 1n full compliance with legal requirements <br /> Technician's Signare-- Date: V-`---i ` � <br /> 5 <br />