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RECEIVED <br />SEP 0 3 7015 <br />Secondary Containment Testing Report Form ENVIRONMENTAL <br />Thu olm is intended or use contractors a <br />forming C aTt� r1CoA OTAACaaT <br />f f by per g periodic testing of UST secondary containment systems. Me e <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 thefaciliry owner/operatorfor submittal to the local regulatory agency. <br />WATION <br />Date of Testing: e, F11 1 <br />Facility Address: Lr' }Zca' w- (-3-,—.ct`ie �p� "Tcx4, J <br />Facility Contact: Phone: <br />Date Local Agency Was Notified of Testing : SB989 — (F ON Cal C <br />Name of Local Agency Inspector (ifpresent during testing); <br />P1 <br />TESTING CONTRACTOR INFORMATION <br />Company Name: ABLE Maintenance, Inc. <br />Pass <br />Technician Conducting Test: - ti <br />,- U <br />Credentials: CSLB Licensed Contractor <br />❑ SWRCB Licensed Tank Tester <br />License Type: A, B, Hie, CIO <br />License Number: 312844 <br />Manufacturer <br />Manufacturer Trainin¢ <br />Component(s)Date TrainingExpires <br />v <br />Aailable upon request <br />❑ <br />o <br />Q <br />❑ <br />3. <br />SUMMARY OF TEST RESULTS <br />Component: <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />Nates: <br />Tank Annular - <br />❑ <br />❑ <br />1 ❑ <br />❑ <br />❑ <br />o <br />Q <br />❑ <br />Secondary Pipe - <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Q <br />G <br />❑ <br />Turbine Sump - <br />❑ <br />❑ <br />❑ <br />❑ <br />UDC - <br />❑ <br />p <br />❑ <br />❑ <br />I P4 <br />G <br />1 ❑ 1 <br />Q <br />Fill Sump - <br />G <br />❑ 1 <br />❑ <br />❑ <br />C1 <br />Q <br />❑ <br />❑ <br />TLM Sump - <br />❑ <br />❑ <br />❑ <br />❑ <br />Spill Bucket - <br />❑ <br />❑ <br />❑ <br />❑ <br />G <br />❑ <br />❑ <br />❑ <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's SignatuM- Date --' <br />