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JUN 12 2015 <br /> Secondary Containment Testing Report Form zNV'IRONMENTA{ <br /> 77tis form is intended for use by contractorrperforming periodic testing of UST secondary containment systebis-, "Ose lluf3�C^T• -•'T <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 ownerloperator for submittal to the local regulatory agency, <br /> 1. FACILITY INFORMATION <br /> Facility Name: Lt�V—ViNAV aU�v'l Date ofTesting:'Y 115 <br /> Facility Address: ©G Y ^;rte ' C Gc�-r <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing: J SB989-3 yr.Compliance <br /> Name of Local Agency Inspector(fpresent duri glasting): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name:ABLE Maintenance,Inc. <br /> Technician Conducting Test: .lames Moore 1 I.C.C.#5254519-UT <br /> Credentials: 0 CSLB Licensed Contractor 0 SWRCB Licensed Tank Tester <br /> License e:A,B,Haz,CIO License Number: 313844 <br /> T:.�..;,,,- ;:,;°.�. .-�..-.......-....-....,...9-.- •'!.^�.y.��uyc•^r�,�y..�x,:. �Fsm..•n--•-.w.r-----�' —_�s::,:_�----'a,.. ;,�:a...,..'�•,r. <br /> Manufacturer Training <br /> Manufacturer Com ovens Date TraffijR&Ex fres <br /> Available upon request <br /> 3. SUMMARY OF TEST RESULTS <br /> Component: Pass Fail Not Repairs Notes: <br /> Tested Made <br /> Tank Annular - ❑ ❑ ❑ <br /> ❑ ❑ [7 ❑ <br /> Secondary Pipe - ❑ ❑ ❑ <br /> 0 ❑ ❑ 0 <br /> Turbine Sump - 0 ❑ ❑ _ <br /> UDC - ❑ ❑ 0 ❑ tit pip <br /> Fill Sump ❑ ❑ ❑ ❑ � <br /> TLM Sump 0 ❑ ❑ 0v <br /> CJ ❑ ❑ ❑ <br /> Spial Bucket - ❑ 0 0 ❑ �c ,G�v�� <br /> ❑ ❑ 1 ❑ 0 <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- Date: <br /> t <br />