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i,:i , , ,� <br />2 <br />MAY 112016 <br />Secondary Containment Testing Report Form <br />This form is intended for use by contractors performing periodic testing of UST secondary containment q iJ7hse:_ <br />appropriate pages of this form to report results for all components tested. The completed form, written test procedures, and <br />printouts from tests (fapplicable), should be provided to the facility ownerloperator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: ..�. — - Date of Testing: Zj ! 16 <br />Facility Address:' -1 • "-- ;�-n �-� -- • r c o�j, �(� <br />Facility Contact: phone: <br />Date Local Agency Was Notified of Testing: f (, SB989 -3 yr. Compliance <br />Name of Local Agency Inspector (#"present during testing): <br />Company Name: ABLE Maintenance, Inc. <br />Technician Conducting Test: James Moore ! I.C.C. #5254517 -UT <br />Credentials: H CSLB Licensed Contractor <br />❑ S WRCB Licensed Tanis Tester <br />License Type: A, B, Haz., C10License Number: 312844 <br />Manufacturer Training <br />Manufacturer Cam onen s Date Training Expires <br />Available upon request <br />11� <br />I.SUMMARY OF TEST RESULIZ <br />Component: <br />MCFE <br />ROM <br />W. 1111MW <br />11� <br />IM-M-911-FINIM <br />��� <br />lam'. <br />SpillBucket <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my knowledge, r <br />a facts stated In this document are accurate and in full conTilance with legal requirements <br />Technician's Signature: Date: 4. i2 - ��' <br />