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L �ty <br /> Secondary Containment Testing Report Form JUL 15 2016 <br /> This form is intended for use by contractors performing periodic testing of UST secondary containment s}, + <br /> appropriate pages ofthis form to report results for all components tested.. The completed Rw <br /> farm, written tett P ¢e �.f%' <br /> printoutrJram tests(ijapplJcableJ,should be provided to the facility owner/operator for submittal to the focal regulatory agency, <br /> I' FACILITY INFORMATION <br /> Facility:Address: <br /> _. � � 4� 2 <br /> Facility 2w/h }mss .:. �.. Ate% Dat¢,, Testin : It /W 16 <br /> Q`�firr`a <br /> Facility :Date Loncy Was Notified of Testing: Phone:Name ofA enc Inspector <br /> i SB989—3 yr.Compliance <br /> 8 Y p (fpresent daring testing): <br /> 2' TESTING CONTRACTOR <br /> COmpan Name:ABLE Maintenance,Inc. INFORMATION <br /> Technician Conducting Test: James Moore/LC.C.ft5254517-UT <br /> Credentials: ® CSLB Licensed Contractor ❑S WRCB Licensed Tank Tester <br /> License Type;A,B,Naz,C10 License Number: alza44 <br /> Manufacturer Manufacturer Train' <br /> Available u on nest Component(s) <br /> 2DatwTrainin Ex ices <br /> 3' SUMMARY OF TEST RESULTS <br /> Component: Pass Fail Not Repairs <br /> Tank Annular - 4Tested Made Notes: <br /> it ❑ ❑ 0 <br /> Secondary Pipe - ❑ ❑ ❑ 0 <br /> 1r ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> Turbine Sump - ❑ ❑ ❑ <br /> ❑ <br /> unc ❑ ❑ ❑ <br /> - ❑✓ ❑ ❑ ❑ <br /> ❑ ❑ <br /> Fill Slurp - ❑ ❑❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> TI M Sump - ❑ 0 ❑ ❑ rive X02 u.� zb <br /> Spill Bucket - ❑ ❑ ❑ ❑ <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 afmy knowledge,the facts stated In this document are accurate and/n full compAance with legal requirements <br /> Technician's Signature: <br /> Date: � (�• 11y <br />