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RECEIVE® <br /> JUN 07 2018 <br /> Secondary Containment Testing Report ForM N �N�RON�M RN AL <br /> This form is intendedfor use by contractors performing periodic testing of USTsecondary 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 /> FACmrry INFORMATION <br /> Facility Name: !ndependent#9435662 s Date of Testing,:05/11/18 , <br /> Facility Address:3505 Navy Dr.,Stockton,CA 95206 <br /> Facility Contact: Phone (209)943-6662 D Initial 0 Repair Tcst <br /> Date Local Agency Was Notified of'I'esting: 04!30118 ❑6 Month ❑Other <br /> Name of Local Agency Inspector(if present durink testing): No Inspector on Site p Triennial <br /> _2. _ TESTING CONTRACTOR INFORMATION <br /> r11 <br /> Com any Name: ABLE Maintenance,Inc. <br /> 'echnicim Conducting Test: Edo Salinger/I.C.C.#872.9425 <br /> Credentials: m CSLB Licensed Contractor D SWRCB Licensed Tank Tester m ICC UST Service Technician <br /> License T A,S,HA .CIO License Number 312844 6 <br /> �`� "M-+����•��-��~---�Manufactgrcr Training, <br /> Manufacturer Component(s) <br /> Date Training F.;`nires _ <br /> n <br /> Available upon request <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Repairs •_..,_��..... — - Not Repairs <br /> Component Pass Fail Component Pass Faii <br /> Tested Made ;iited glade <br /> _ <br /> Tank 1 Annular _ O -- 0 <br /> Seoondsiy Product 1 <br /> Secondary Product 2 _ -� i� ❑ <br /> Turbine Sump 1 _ <br /> t7 D <br /> tJDC Not Equipped ® i— D O O <br /> Fill Sump Not Equipped _ <br /> SRII Bucket Not Equipped LJ __ D ❑ y <br /> u ❑ <br /> El <br /> u U <br /> --- ----- -- -- 0 <br /> L7 <br /> —_ —.. _ a ❑ 0 1n o ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> Used Pump Test Truck <br /> For any equipment capable of generating a print out of test results,you must attach a copy <br /> of the test report to this certification ❑ System printout attached. <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 /> Tcchnician's Signature:,,_ Date: 05/11/18 <br />