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s <br />Secondary Containment Testing Report Form <br />This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the <br />appropriate pages ofthis farm to report results for all components tested The completedform, written test procedures, and <br />printouts from tests (fapplicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1. FACILITY TNFORNTATTON <br />2. TRRTMGC'ONTRArTOR MVORMATTON <br />Company Name: ABLE Maintenance, Inc. <br />Technician Conducting Test: J2Mes Maare1I.C.C.#52545I7-UT <br />Credentials: ® CSLB Licensed Contractor <br />❑ SWRCB Licensed Tank Tester <br />License Type: A, B, Ilan, CIO <br />License Number: 312844 <br />Manufacturer <br />1110 <br />Manufacturer Training <br />Cam onent s Date Training Expires <br />Available upon request <br />3. RTTMMARV OF TEST PF.,qTl7.TG <br />If jiydrost tic testing was performed, describe what was d e with the water after completion of tests: <br />--0jW M 5 I e' V i-- uh S l <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my knoWerlg , the fa stater! in this document are accurate and in full compliance with legal requirements <br />Technician's Signature: Date: <br />Secondary <br />Turbine Suinp <br />MINIMUM <br />t <br />If jiydrost tic testing was performed, describe what was d e with the water after completion of tests: <br />--0jW M 5 I e' V i-- uh S l <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my knoWerlg , the fa stater! in this document are accurate and in full compliance with legal requirements <br />Technician's Signature: Date: <br />