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Secondary Containment Testing Report Form <br /> This form is intendedfor use by contractors peg forming periodic testing of UST secotadary containment <br /> systems. Use the <br /> appropriate pages of this form to report results for all components tested. The canond ar form, written test procedures, and <br /> pritxtozrts from tests(if applicable), should be provided to the facility owner/operator for sztbtnittal to the local reg <br /> zrlatoty agency. <br /> 1. FACILITY INFO <br /> FacilttyName: ARCO# --� RMATION <br /> Facility Address: _ Date of Testing: /-I— <br /> Fac i lity Contact: <br /> -I—FaciIityContact: <br /> Date Local Agency Was Notified of Testing: Phone: <br /> du <br /> Natrte of Local Agency Inspector i SB989—3yr•Compliance Test <br /> P (fpresent ring testing): <br /> 2. <br /> Company Name:ABLE Maintenance,Inc. TESTING CONTRACTOR <br /> FORMATION <br /> Technician C-4---j- - James Moore/I.C.C.#52545X7-UT <br /> Credentials: ® CSLB Licensed Contractor <br /> License Type:A B,Haz.,CIO ElSWRC8 Licensed Tank Tester <br /> License Number: 312844 <br /> Manufacturer Manufacturer Tramin <br /> Available upon request Com onen s <br /> Date Trainino Ex fres <br /> 3. <br /> SUMMARY OF TEST RESULTS <br /> Component: Pass Fall Not Repairs <br /> Tat2I< .nnuja.r _ Tested Made Notes: <br /> � ' ❑ ❑ <br /> Secondary Pipe - ❑ ❑ 0 0 <br /> -❑ 0 ❑ ❑ <br /> Turbine Sump - 3 ❑ ° 0 0 <br /> ❑ ❑ ❑ <br /> UDC - ° ° ❑ ❑ <br /> 0 0 0 1 <br /> Fill Sump - 0 ❑ 0 ❑ <br /> ❑ ❑ ❑ <br /> TLM Sump - 0 ❑ 0 ❑ <br /> Spit( Bucket - 0 0 ° 0 <br /> ❑ ❑ 0 <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 ttzy/rnozpledge,the facts stated In this doctunent are accurate and!"full cotxzpliance with legal requirements <br /> Technician's Signature: <br /> Date: <br />