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Secondary Containment Testing Report Form <br /> This,(brnt is intended for use by contractors peifornting periodic testing of UST secondary containment systems. Use the <br /> appropriate pages ofthis form to report results for all components tested. The completedform, written test procedures, and <br /> printouts from tests(if applicable), should be provided to thefacili0+owner/operator for submittal to the local regulatory agency. <br /> I. FACILITY INFORMATION <br /> Facility Name: ARCO# l nGU Date of Testing: 141/,65-1 07 <br /> FacilityAddress: 5o N W1�Sw WbY Iry eJ e, <br /> Facility Contact: Phone: o s 52 q+ <br /> Date Local Agency Was Notified of Testing: SB989—3yr. Compliance Test <br /> Name of Local Agency Inspector(iifpresent during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: ABLE Maintenance, Inc. <br /> Technician Conducting Test: James Moore/ I.C.C.#5254517-UT <br /> Credentials: ® CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester <br /> License Type: A, B,Haz., C10 License Number. 312844 <br /> Manufacturer Training <br /> 'Manufacturer Com onent s Date Training Expires <br /> Available upon request <br /> 3. SUMMARY OF TEST RESULTS <br /> Component: Pass Fail Not Repairs Notes: <br /> Not <br /> Made <br /> Tank Amutlar - 9j ❑ ❑ ❑ <br /> ❑ ' ❑ I ❑ ❑ <br /> Secondary Pipe - -�7 Rf ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> Turbine Sump ❑ ❑ ❑ Q . <br /> UDC - e ❑ id ❑ ❑ / <br /> Fill Sump - -;77 ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> TLM Sump - ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> Spill Bucket - lP ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br /> CERTIFICATI N OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of try kno+v(erlge, t! facts slater!in skis document are accurate and rn full comp[im+ce iv/tl+legal regnireutents <br /> Technician's Signature: - Date:_t c7-Z'/51 <br /> i <br />