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Seco <br />econdary Containment Testing Report Form <br />This form is intended for use bi; contractors perfo, ming periodic testing of USTsecondaty containment systems, Us2the <br />appropriate pages q1*t.'dsJoan to report r,-suhsfor all components tested The completed form, written test procedures, and <br />printouts from tests (if applicable), should be provided to the facility own.,r1operatorj6r submittal to the local regulatory agency, <br />FACILITY DWORMATION <br />Facility Name: Date of Testing: 0/ <br />Facility Address: <br />Facility Contact. Phone: <br />Date Local Agency Was Notified of Testing: SB989 — <br />[-Name of Local Agencv InsDector (it"Presenj during fesfina)- <br />Company Name: ABLE Maintenance, Inc. <br />Technician Conducting Test: . ..... <br />0 CSLB licensed Contractor 0 SWRC8 Licensed Tank Tester <br />License Type; A, 8, Hoa., CIO 'License Number: 312844 <br />Manufacturer Trainin <br />Manufacturer Component(s) Date Training Expires <br />Available upon re ;t <br />. .......... . ......... . . ..... <br />I <br />Component., <br />Tank Annular - <br />flint 1110 <br />Eime-if 1- 1 <br />illi lrl��i�iru�W <br />If hx,,drostatic testing was performed, describe what was done with the water after completion of tests: <br />. ...... --- <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 fn full compliance with legal requirements <br />Technician's Signa Date: <br />