Laserfiche WebLink
Secondary Containment Testing Report Form <br />This form is Intended for use by contractors performing periodic testing of UST secondary containment systems. Ilse the <br />appropriate pages of thisform to report results for all components tested The completed form, written test procedures, and <br />printouts from tests (if applicable), should beprovided to the facility ownerloperatorfor submittal to the local regulatory agency. <br />I. <br />I <br />Facility Name: (.o Date of Testing: V 1 13 <br />Facility Address: <br />Facility Contact Phone: <br />Date Local Agency Was Notified of Testing :,�—Y SR989 –3 yr. Compliance <br />Name of Local Agency Inspector (Ifpresent during twang): <br />110 all) ZIN ��# � <br />Company Name: ABLE Maintenance, Inc. <br />Technician Conducting Test; James Moore / I.C.C. #5254517 -UT <br />Credentials: N CSLB Licensed Contractor D SWRCB Licensed Tank Tester <br />License Type: A, B, Haz., CIO I License Number: 312944 <br />Available <br />3. <br />Im <br />Component. <br />11 <br />Secondary Pipe - <br />"A <br />- MM� <br />g <br />Spill Bucket - <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 />ro the best of my knowledge, he stated in this document are accurate and In full conWilance with legal requirements <br />Technician's Signature. Date: <br />T\J: N& :7 <br />