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• 0 <br /> Secondary Containment Testing Report Form <br /> This form is intended for ttse 4v contractors performing periodic testing of UST secandcuy containment systems. Use the <br /> appropriate pages of thisform to report results,for all componems tested. The completedform, written test procedures, and <br /> pr•intoutsfrotn tests(fopplicable). should be provided to thejncilitp ownerloperatorforsubmittal to the local regulatory ngencv. <br /> 1' FACILITY INFORMATION <br /> Facility Name, ARCO# <br /> Facility Address: Date of Testing:l2/1-k—/ 07 <br /> Facility Contact: <br /> Phone: <br /> Date Local Agency Was Notified of Testing: hone: <br /> Name of Local Agency Inspector(fpresent during testing): L>ry <br /> 2' TESTING CONTRACTOR INFORMATION <br /> pManLifacturer <br /> : ABLE Maintenance, lnc. <br /> ducting Test: James Moore/I.C.C.#5254517-UT <br /> ® CSLB Licensed Contractor D SWRCB Licensed Tank Tester <br /> , B,Haz.,CIO License Number: 312844 <br /> Manufacturer Traininurer Com onent s <br /> Available upon request Date Training Ex fires <br /> 3• SUMMARY OF TEST RESULTS <br /> Component: Pass Fail Not Repairs <br /> Tank Atmulaz• <br /> Tested Made Notes: <br /> - 3 <br /> ❑ ❑ 0 MAAAFQp TANd9 ¢' T�s 5aJ <br /> ❑ ❑ ❑ 0 <br /> Secondary Pipe - 0 ❑ ❑ 0 <br /> ❑ ❑ 0 ❑ <br /> Turbine Sump - 1 0 0 512�ftm tv"m,O <br /> UDC - .y ❑ ❑ <br /> t C� <br /> ❑ 0 ❑ ❑ <br /> Fill Stunp - ❑ ❑ ❑ ❑ T <br /> TLM Sump - ❑ ❑ ❑ ❑ <br /> Spill Bucket - ❑ 0 0 0 <br /> ❑ ❑ ❑ ❑ <br /> If ydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> 2 f7A�JasS.1. 6yj 5I <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best ofnty knowledge, to fac stated in this document are accurate and in full compliance wUh legal requirements <br /> Technician's Signature: Date: <br />