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Secondary Containment Testing Report Form <br />JAN 11 20116 <br />This form is intended for use by contractors performing periodic testing of UST secondary containment syslemr it"+tt,�,�N' <br />appropriate pages of this form to report results for all components tested. The completed form, written test procedarp,-�gtad,rn8 PTnPCN r <br />printoutsfrom tests (ifapplicable), should be provided to thefacility owner/operatorforsubmittal to the local regulatory agency. <br />R s rrr rry TNFnRMA TTON <br />Facility Name:��r 2 tTk Dete of Testing: d. to/ 15 <br />FacilityAddress:W�1� N.'ryx <br />Facility Contact: phone: <br />Date Local Agency Was Notified of Testing : - I May yr. Compliance <br />Name of Local Agency Inspector (fpresent during testing): <br />f-r0R rNRARMATYnN <br />2. <br />_______-__--- <br />Company Nome: ABLE Maintenance, Inc. <br />Technician Conducting Test: James Moore / I.C.C. 45254517 -UT <br />Credentials: S CSLB Licensed Contractor <br />D SWRCB Licensed Tank Tester <br />License Type: A, B, Hay-, CIO <br />License Number. 312844 <br />Manufacturer Treinina <br />Manufacturer <br />Cam onent s Date Training Expires <br />Available upon request <br />_ -- <br />ITTatedRepairs <br />Pipe <br />ar rMM A Rv !1F TF.IFT RESULTS <br />Component: <br />Paas <br />Made <br />Notes: <br />Tank Annular - <br />❑Secondary <br />ITTatedRepairs <br />Pipe <br />n <br />TurbineSump <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />UDC . <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Fill Sump ?' <br />vgews; 50tt-t <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />TLM Sump - ¢ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />� <br />Spill Bucket . e <br />❑ <br />❑ <br />❑ <br />-z—QzQ <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />__�Wr <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my knowledge, the facts stated in this document are accurate and to full compliance with legal requirements <br />S ' 14 <br />Technician's Signet <br />_�� Date: n <br />^•' <br />