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Secondary Containment Testing Report Form <br />This form is intendedfor use by contractors performingperiodic testing of UST secondary containment systems. Use the <br />appropriate pages of this form to report reszrlts for all components tested. The completed form, written fest procedures, and <br />printouts front tests (f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1' FACILITY INFORMATION <br />Facility Name: ARCO# 2 1 � <br />Facility Address: Date of Testing: 14- /=-9, <br />Facility Contact: <br />_ Phone: <br />Date Local Agency Was Notified of Testing : <br />Name of Local Agency Inspector (if present during testing): SB989 —3yr. Compliance Test <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: ABLE Maintenance, Inc. <br />Technician Conducting Test: _ rnall? OfSON <br />Credentials: I CSLB Licensed Contractor ❑ SWRCB Licensed Tank Tester <br />License Type: A, B, Haz., CIO License Number: 312844 <br />I - <br />Manufacturer TraininLr <br />Manufacturer Com onent(s) <br />Available upon request Date Training Expires <br />3. CTTXA-NYFA err nn <br />41 n�urusiauc resnng was perrormed, describe what was done with the water after eomnletinn nfrPar�• <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of nzy knowledge, the facts stated in this document are accurate and In full cotnpliance with legal requirements <br />Technician's Signaturei�'e,� <br />Date: <br />