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RECEIVEO <br />FEB 0 3 2017 <br />Secondary Containment Testing Report Form NMEINTAL HEALTH <br />, sy�N ' V ; <br />This form is intended for use by contractors performing periodic testing of USTsecondwy containment ej! A TMENT <br />appropriate pages of this form to report results for all components tested. The completedform, written tat prol <br />from tests (if applicable), should be provided to the ownerloperatorfor submittal to the local regulatory agency. <br />printoutsf cill <br />FACILITY INFORMATION <br />x <br />Facility Name. Date of Testing: 16, <br />Facility Address: Iq - <br />Facility Contact: f Phone: no') Zq A- Pl- <br />15iieocal Agency as Notified of Testing: SB989 - 3 yr. Compliance <br />,Name of I ocai Agency Inspector (present during testing); <br />Company Name: ABLE Mal— <br />poss <br />Technician Conducting Test. Shaun Malone IX.C. W20932 <br />Credentials. Z CSLB Licensed Contractor <br />D SWRCB Licensed Tank Tcster <br />'i License Type: A, A Hoz., CIO <br />t T Manufacturer <br />— <br />1' License Number: 312844 <br />Manufacturer Training <br />Componn!(�� Date Trainin Ex ires <br />Available upon request <br />D <br />WOM <br />Component; <br />poss <br />Fail <br />Not <br />Tested <br />Repairs <br />NUde <br />Notes: <br />Tank Annul_®--_, <br />ar❑D <br />[Tan AiinEular <br />D <br />❑ <br />n <br />I] <br />Secondary Pipe <br />-1 <br />Li <br />[71 <br />❑i <br />D <br />��uTbine Sump �-2 <br />F] <br />n <br />0 <br />51 <br />❑ <br />D <br />UDC <br />0 <br />0 <br />Fi Esunip - —0— <br />D <br />0 <br />0 <br />D <br />D <br />0 <br />TLM Sump <br />n <br />/U <br />Spill Bucket <br />Ll <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 AM COMP11ance with legal requirements <br />I /' <br />oel I <br />Technician's Signalu Date:-_ / <br />