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*RECEIVED <br /> DEC 3 0 2016 <br /> Secondary Containment Testing Report FormENVIRONMENTAL HEALTH <br /> This form is intended for use by contractors performing periodic testing of UST secondary containment systems.I <br /> jP(A11TMENT <br /> appropriate pages of this form to report results for all components tested The completed form,written test proc res,and <br /> printouts from tests(if applicable),should be provided to the facility ownerloperatorfor submittal to the local regulatory agency. <br /> 1. Y',kCll ITY INF01MA TTON <br /> Facility Narne: Date of TeLt!n •i. 16 <br /> Facility Address: 0-0 ---------- <br /> Facility Contact: <br /> -T:�'jione: M- +73- '7317 <br /> of sti, <br /> i Date Local Agency Was Noti ied i1g. yr.complIance <br /> it Name of Local Agency Inspector(f present during testing <br /> 2. TESTING COTIIILICT OR W14'ORMATION <br /> Company Name:ABLE Maintenance,Inc. <br /> Technician Conducting Test: Chris Graham I I.C.C.#5252492-VT <br /> Credentials: 9 CSL B Licensed Contractor 0 SWRCB Licensed Tank Tester <br /> License Type:A,B,Haz.,CIO W License Number, 312844 <br /> Manufacturer —Marwfleturer D1-111-31M) Date T <br /> ira►ni�Ex fires <br /> 3. SUNIMARY 0F TEST IMULTS <br /> .'Vol <br /> Component: Pass Fall Teed Made Notes: <br /> Tank Annular A 0 0 F1 <br /> Secondary Pipe "5N;kl <br /> U C F.1 <br /> • Turbine Sump D 1M El <br /> 0-- 0 <br /> �-1e0zvU%W-1';C <br /> UDC 0 K,® <br /> 0 n U <br /> "Fill Sumv &r 0 U 0 <br /> SIL� <br /> P 0 L] 0 U <br /> I SDIII Bucket L I <br /> If hydrostatic testing was perfonned,describe what was dofiv with tine wat,�,r after completion of tests: <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,the facts stated in Mie document are accurate and in full compliance with legal requirements <br /> Technician's Date:- 1A .-° -'---- <br />