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Secondary Containment Testing Report Form <br /> This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the <br /> appropriate pages of this form to report results for all components tested. The completed farm, 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 INFORMA110N <br /> Facility Nam ,Q�s r� Date of Tessin : 12 <br /> Facility Address: t�v— <br /> Facility Contact: Phone:_ <br /> Date Local Agency Was Notified of Testing: '' ) /� SB989—3 yr.Compliance <br /> Name of Local Agency Inspector(rf present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name:ABLE Maintenance,Inc. <br /> Technician Conducting Test: James Moore I I.C.C.#5254517-UT <br /> Credentials: ® CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester <br /> License Type:A,B,Haz.,CIO License Number: 312844 <br /> W + Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> Available upon request <br /> -3._3. SUMMARY OF TEST RESULTS <br /> Component: Pass Fail Not Repairs Notes: <br /> Tested Made <br /> Tank Annular - ( 0 ❑ ❑ <br /> Secondary Pipe -'� ❑ ❑ ❑ <br /> y <br /> El ❑ <br /> Turbine Sump - 0 0 ❑ <br /> 0 0 ❑ ❑ <br /> UDC - 0 ❑ ❑ ❑ ,mac, <br /> Fill Sump z- 0 ❑ 0 ❑ ( `YJ <br /> 0 0 0 ❑ <br /> TLM Sump ❑ ❑ ❑ 0 Cys v �ttp <br /> ^_. ❑ ❑ ❑ ❑ <br /> Spill Bucket ❑ ❑ C ❑ <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,the facts stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: Date:' __ 1rZ <br />