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Secondary i t Testing ReportForm <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 (f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency, <br />1. <br />Facility Nam : Date of Testin : � 7 A - /1'',r <br />Facility <br />Facility Contact: Pizone: <br />Date Local Agency Was Notified of Testing: SB989 <br />Name of Local Agency inspector (fpresent during testing): <br />Company Name: ABLE Maintenance, Inc. <br />Technician Conducting Test: ,fames Moore 1, CC. # 5254517 -UT <br />Credentials: 0 CSLB Licensed Contractor ❑ SWRCB Licensed Tank Tester <br />License Type: A, B, Hoz., Citi License Number: 312844 <br />Manufacturer <br />ILdning <br />Manufacturer Colts onst s Date Trainin Ex fres <br />Available upon request <br />3. <br />SUMMARY RESULTS <br />Turbine 1�E.I <br />6 f <br />ttw>w*+w <br />! • <br />I <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />CERTIFICATION OF RESPONSIBLE FOR CONDUCTING <br />