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Secondary Containment Testing Report Farm <br />This form is intended f tr use by contractors perfortning periodic testitis; of UST secondary containment systems. Case the <br />appropriate pages of this form to report results far all components tested. The completed form• wrilten lest procedures, and <br />priniouts,from tests (if applicable), should be provided to the: facility owner/operwor for submittal to the local regulator;. agency. <br />1. FACILITY INFORMATION <br />Facility Name: Shell -136186 1 Date of Tcsting: 11/14/07 <br />Facility Address: 3725 N. Tracy Blvd - Tracy <br />Facility Contact: Phone: <br />Date local Agency Was Notified of Testing: SB989 —Repair & Retest <br />Name of Local Agency Inspector of present during testing;): <br />2. TESTING CONTRACTOR INFORMATION <br />Company Dame: ABLE Maintenance, Inc. <br />Notes: <br />Technician Conducting Test: Mike Trejo 1 I.C.C. #5252033 -UT <br />Credentials: ® CSLB Licensed Contractor <br />SWRCB Licensed 'I'anli Tester <br />License Type:.A, B, liaz., C1tP <br />License Number: 312844 <br />Manufacturer <br />Manufacturer Training <br />Com onent(s) Date Training, Expires <br />Available upon request <br />Turbine Sump - 1 0 <br />UDC - <br />3. SUMMARY OF TEST RESULTS <br />Component: Pass Fail Not Repairs <br />Tested Made <br />Notes: <br />Tank Annular - <br />Secondary Pipe - <br />Turbine Sump - 1 0 <br />UDC - <br />Fill Sump - <br />TLM Sump - <br />Spill Bucket - <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />Used drum already on site <br />CERTIFICATION OF TECIINICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my knowledge, the facts stated in this doc•untent are accurate and in full compliance with legal requirements <br />Technician's Signature: __ _. Date: <br />