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Secondary Containment Testing Report Form This form is intendedfor use by contractors performing periodic testing of UST secondary containment systems. Use the appropriate pages of this form to report results for all components tested. The completed form, written test procedures, and printouts from tests (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. 1. FACILITY INFORMATION Facility Name: S 1- .), I S'�, Date of Testing: 11 / g / 0-1 Facility Address: `22,5 Ja(, t UVC) Facility Contact: Phone: Date Local Agency Was Notified of Testing: SB989 — 3yr. Compliance Test Name of Local Agency Inspector (if'present during testing): 2. TESTING CONTRACTOR INFORMATION Company Name: ABLE Maintenance, Inc. Technician Conducting Test: k\4.1: Credentials: ® CSLB Licensed Contractor ❑ SWRCB Licensed Tank Tester License Type: A, B, Haz., CIO License Number: 312844 _.,...: .. v -.: >ax. u..,.. x. - . x mr�..� _.-, r�:? .:..r Manufacturer zx � .xav!t •m.*acrs..,..3„. .... .........a..-e.....�e>~rvv • .�.... � _ t., . .. Manufacturer TraininI Component(s) Date Training Expires Available upon request i 3. SUMMARY OF TEST RESULTS If hydrostatic testing was performed, describe what was done with the water after completion of tests: CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING To the best of my knowledge, the facts stated in this document are accurate and in full compliance with legal requirements Technician's Signature: %�,�_ (` Date: i Fill Sump Imuf • ��--i Spill- ©�®0 If hydrostatic testing was performed, describe what was done with the water after completion of tests: CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING To the best of my knowledge, the facts stated in this document are accurate and in full compliance with legal requirements Technician's Signature: %�,�_ (` Date: