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E <br />Secondary Containment Testing Report ForgiNVIRONMENTAL HEALTH <br />DEPARTMENT <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 form, written test procedures, and <br />printouts from tests (if applicable), should be provided to the facility ownerloperatorfor submittal to the local regulatory agency. <br />0 WEt H L�j W A rikA-" RLaWAd <br />5TA <br />Company Name: ABLE Maintenance, Inc. <br />:J <br />I Technician Conducting Test: Shaun Malone#8320932 <br />Credentials: 0 CSLB Licensed Contractor <br />0 SW�,CB Licensed Tank Tester <br />License Type: A, B, HCIO <br />License Number: 3128" <br />Tank AiTi —a.—t <br />Manufacturer Training <br />Date Trainin E ires <br />Available upon request <br />r] <br />El <br />❑Yo <br />MUE�� <br />Component, <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />I Made <br />Notes: <br />Tank AiTi —a.—t <br />D <br />r] <br />El <br />❑Yo <br />❑0 <br />0 <br />Secondary i e -3 <br />irl <br />0 <br />0 <br />0 <br />E- <br />0, <br />El <br />11 <br />Turbine Sump <br />V/ <br />0 <br />n <br />I 'D <br />0 <br />1-1 <br />Cl <br />F1 <br />Fj <br />Ej <br />LJ <br />Fill Sump <br />E, <br />10 <br />I <br />0 <br />0 <br />- f - <br />F -j <br />o <br />0 <br />o <br />TLM Sump <br />0 <br />0 <br />0 <br />1 Fi <br />. . . . .. ...... ......................... <br />Spill Bucket <br />L <br />El <br />Ei <br />0 <br />0 <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of nay knowledge, the facts steeled in this document a e accurate and in fall compliance with legal requirements <br />Technician's Signature: mate:_!IL <br />