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FEB 0 3 2017 <br />Secondary Containment Testing Report ForIfiNVIRONMENTAL HEALTH <br />This form is intended for use by contractors performing periodic testing of LIST secondary containment systemE?ffQ04QTMENT <br />appropriate pages of this form to report results for all components tested The completed form, written test procedures, and <br />printouts from tests (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1. FACILITY ITtFnRMAT101V <br />Facility Name: - --Date of Testing: <br />Facility Address: '� <br />Facility Contact1 Phone: C 2 <br />Date Local Agency Was Notified of Te ng :,f SB989 —3 yr. Compliance <br />Name of Local Agency Inspector (ifpresent during testing): <br />Company Name: ABLE Maintenance, Inc. <br />Technician Conducting Test: Shaun Malone I I.C.C. #8320932 —� <br />Credentials: ® CSLB Licensed Contractor 0 SWRCB Licensed Tank Tester <br />License Type: A, B, Haz., CIO v License Number: 312844 <br />Manufacturer Training <br />Manufacturer _ _ Component(s) _ , Date Training Expires <br />Available upon reg nest <br />3. SITMMARV OF TEST RF.g11T.TQ <br />Component: <br />Pass <br />fail <br />Not <br />Tested <br />RepAra <br />Made <br />Notes: <br />Tank Annular <br />_ <br />❑ <br />❑ <br />❑ <br />❑ <br />Secondary Pipe _3 <br />V❑ <br />U <br />U <br />_ <br />C1 <br />11 <br />❑ <br />– <br />Turbine Sump - <br />❑ <br />[] <br />- <br />q /7P <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />U <br />— <br />_ <br />❑ <br />❑ <br />❑ <br />❑ <br />—__ _ _ _' <br />Fill Sump <br />V ❑ ❑ <br />❑ <br />0 <br />0 <br />❑ <br />❑ <br />TLM Sump_- <br />❑ <br />❑ <br />❑ <br />❑ <br />_..� _ <br />Spill Bucket - lj <br />❑ U <br />❑ <br />a <br />o <br />❑ <br />❑ <br />T <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, thefacts stated in this document are accurate and in full compliance with legal requirements <br />Technician '$ Signature: Date:! �" `~ <br />