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ftCEIVED <br /> JAN 0 3 2017 <br /> Secondary Containment Testing Report For`/Im[�(�nI <br /> This form is intended for use by contractors performing periodic testing of UST secondary conlaNYJAt tyS ht A�EUTA� HEALTH <br /> appropriate pages ofthis form to report results for all components tested The completedform, written f ME-W <br /> printouts from tests rif applicable),should be provided io the facility owner/operator for submittal to the local regulatory agency. <br /> I• FACIt.ITY INFORivIA/TON <br /> Facility Name: ate ofTcaing: <br /> Facility Contaa: <br /> Phone; — <br /> Date Local Agency Was Notified of Testing: ��, . SE989-3 yr.Compliance <br /> Name, Name of Inspector(ifpresent during iaeiing) <br /> 2• TESTING CONTRACT TOR INtYtldtri',L'f10Y <br /> Company Name: ABLE Maintenance,Inc. <br /> Technician Conducting Test: Chris Graham/T.C.C.85252492-UT ---II <br /> Credentials:_ _0 CSLB Licensed Contractor ❑SWRC_E Licensed Tank Tester _ <br /> License Type:A,B,Haz,CIO License Number: 312844 <br /> --Maaufacturer TrainhIC <br /> Manufacturer --Component s) Data Training Expires <br /> Available upon request <br /> 3. SUMMARY OF TEST RESULTS _ <br /> h...,.m:...�....,.._.<..m.,®.....�.,._ -- Not Repnlrs <br /> Pass Mall r s Nota: <br /> Tooted Mau. <br /> Tank Annular - �-` _ a ❑ I ❑ ri <br /> ❑ ❑ 11 I ❑ <br /> Secondary ape-� __-_ 0 lY ❑ CI "l7--- <br /> �_ ❑ ❑ t_ ❑ ❑ lt'� 'W � zo`t' <br /> I Turbine Sump - II C <br /> U ❑ ❑ ❑ <br /> DC ❑ Joan PG <br /> —�_ ❑ aI ❑ r M <br /> Fill Sum ❑ L7 - -_❑ --`,—F _ ❑ M ❑ ❑ _'�lu AML } t.1ti'�'Q <br /> LM Sum r L! El ❑ <br /> Spill Bucket - 'jr ❑ - ❑ r— <br /> If hydrostatic testing was performed,describe what was done with the water after completion of teats: <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,rhe facts statedinthis document are accurate and in full compliance with legal requirements <br /> Technician's Signature:___._ I r^�1 <br />