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RECEIVED <br /> Secondary Containment Testing Report Form SEP 2 2 2016 <br /> This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the <br /> appropriatepages ofthisform to report resultsfor all components tested The completedform, writEWjFG Eit4TAL HEALTH <br /> printoutsfrom tests(ifopplicable),should be provided to the facility owner/operator far submittal to the locatm#ARTMEANT <br /> FACILITY INFORMATION <br /> Facility Nam . . (.,mss to\-L, Date of Testing:zv iK`16 <br /> Facility Address: Ie�' 51--{7lj \_ rps o1C;� L,7 <br /> Facility Contact: phone: <br /> Date Local Agency Was Notified of Testing: 1p SB989—3 yr. Complianze :I <br /> Name of Local Agency Inspector(fpresent durirg testiow): <br /> _ 2. _ VESTING CONTRACTOR INF01MIAT_I_ON 11� <br /> Company Name:ABLE Maintenance, Inc. w R 4 <br /> Technician Conducting Test: James Moore/I.C.C.45254517-UT <br /> Credentials: 0 CS1,13 Licensed Contractor C SWRCB Licensed Tank Tester I <br /> License Type A,B,Haz.,CIO License Number. 312844 <br /> Manufacturer Training <br /> Manufacturer Com onent(s) Date TrainingExpires ;l <br /> Available u on re uest <br /> —_� <br /> 3. S_UMMARV OF TEST RESULTS <br /> Component: Pass Fail toot Repairs Notes: <br /> ' <br /> Tested Made ° t <br /> Tank Atmular - 1 1, ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> Secondary Pipe - ¢ ❑ ❑ 1-1 <br /> Turbine Sump - 'L ❑ ❑ ❑ --" <br /> ❑ G' CJ <br /> UDC - ?/ ❑ ❑ ❑ <br /> n u ❑ ❑ <br /> Fill Sump - ❑ n ❑ <br /> ❑ ❑ ❑ ❑ <br /> TLM Sump - ❑ ❑ ❑ ❑ — - <br /> �� +ems <br /> Spill Bucket - 4 ❑ ❑ u <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,! e facts stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: <br />