Laserfiche WebLink
Secondary Containment Testing Report Form <br /> This form is Intendedfor 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 /> Facility esting:2-/ / <br /> Facility Address: <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing: SB989— <br /> Name of Local Agency Inspector(tfpresent during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name:ABLE Maintenance,Inc. <br /> Technician Conducting Test: James Moore I.C.C.#5254517-UT <br /> Credentials: 10 CSLB Licensed Contractor 0 SWRCB Licensed Tank Tester <br /> License Type:A,B,Haz.,C10 License Number: 312844 <br /> ?§PAY±7_!i!�!!4;#4RSiJ ?Ti�_:i�►:'�Yj:i.�.-g,-�+.s`�L�_ �. - - yc�r�� <br /> Manufacturer Training <br /> Manufacturer Com nen s Date Training E ires <br /> Available upon request <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Notes: <br /> Tested Made <br /> Tank Annular - ❑ ❑ ❑ ❑ <br /> ❑ a ❑ ❑ <br /> Secondary Pipe - ❑ ❑ 1 ❑ ❑ <br /> ❑ ❑ 0 ❑ <br /> Turbine Sump - ❑ ❑ ❑ ❑ <br /> O 0 ❑ 0 <br /> UDC - 0 ❑ ❑ <br /> 0 ❑ ❑ ❑ <br /> Fill Sump - ❑ ❑ ❑ ❑ <br /> ❑ ❑ 0 ❑ <br /> TLM Sump - ❑ ❑ ❑ ❑ <br /> 0 ❑ ❑ ❑ <br /> Spill Bucket - ❑ ❑ ❑ ❑ <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:---•--V----jVV-\ Date: '7" I 'I 13 <br />