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Secondary Containment Testing Report Form <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(f applicable), should be provided to the facility owner/operator far submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: 77-—C* I ILVF-3 L.'s Date of Testing:5; r7-1 15 <br /> Facility Address: �Os�. Y ,L rc�" rc Cwt Kph <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing: 5 �� SB989—3 yr.Compliance <br /> Name of Local Agency Inspector(tfpresent during esting): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: ABLE Maintenance,Inc. <br /> Technician Conducting Test: James Moore/LC.C.#5254517-UT <br /> Credentials: N CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester <br /> License Type:A,B,Haz,C10 License Number: 312844 <br /> Manufacturer Training <br /> Manufacturer Com onen s Date Training Expires <br /> Available upon request <br /> I <br /> Ln <br /> 3. SUMMARY OF TEST RESULTS ., <br /> Component: Pass Fail Not Repairs Notes;- <br /> Tested Made <br /> Tank Annular - ❑ ❑ _ ❑ ��� , <br /> ❑ ❑ ❑ ❑ reA�Arr <br /> Secondary Pipe - r ❑ I -1 ❑ <br /> ❑ ❑ ❑ ❑ <br /> Turbine Sump - ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> UDC - ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> Fill Sump ❑ ❑ ❑ ❑ 1 � <br /> TLM Sump - 0 ❑ ❑ ❑ �v �;�-�p <br /> ❑ ❑ ❑ ❑ <br /> Spill Bucket - ❑ ❑ ❑ ❑ �ezvv� <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 /> .. i <br /> i <br /> Technician's Signature- Date: a� l 'Z •1`� <br /> r <br />