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� RECEIVED <br /> FFB 16 W7 <br /> Secondary Containment Testing Report Form ENVIRONMENTAL HEALTH <br /> The,form is intended far use by contractors performing periodic testing of UST secondary containment systems. Use6F PpRTMENT <br /> appropriate pages ofthes form to report results for all components tested The completed form,written test procedures, and <br /> printouu from tests(Jf applicable),should be provided to the factlity owner/operator for submittal to the local regulatory agency. <br /> I. FACILITY INFORMATION <br /> Facility Name: Date of Testing: J / 117 , / —. <br /> Fscility Address: <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing: )p 10 <br /> Name of Local Agoncy Inspector(ifpresem during testing): <br /> 2, TESTING CONTRACTOR INFORMATION <br /> Company Name:ABLE Maintenance,Inc. <br /> Technician Conducting Test: Shawn Sbragin I.C.C.#5307967 <br /> Credantials: ® CSLB Licensed Contractor ❑SWRCB Licensed Tank rester <br /> License Type:A,B,Hao,C10 License Number: 312844 <br /> Manufacturer Training <br /> Manufacturer Com ncn s Date Training Expires <br /> Available upon r gest <br /> 3, SUMMARY OF TEST RESULTS <br /> Not Repairs Not <br /> Pass Pail es. <br /> Component: Tested Made .— <br /> Tank Anmular - ❑ ❑ - Gt 0 - <br /> ❑ ❑ ❑ 0 <br /> Secondary Pipe - A ❑ ❑ in <br /> l ' <br /> 0 ❑ 0 ❑ TWW <br /> Turbine Sump - ❑ ❑ C9 <br /> UDC - 0 ❑ 6ty <br /> ❑ n n ❑ SU <br /> Fill Sump - ❑ ❑ c" <br /> ❑ 0 ❑ ❑ - <br /> TLM Sump ❑ ❑ ❑ <br /> ❑ 0 ❑ ❑ <br /> Spill Bucket - ❑ ❑ � ❑ <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 ofmy Jwowkdgc,the facts slated In this document are accurate and hs fall compliance with <br /> 1rlegal <br /> Irequirements <br /> Technician's Signature:& �4� Date._ <br />