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{ <br />DEC -05-2008 12:22 Service Station Systems 408 938 8888 P.02 <br />Secondary Containment Testing; Report. Form <br />t'h'is form is. interacted for use by contractors perfornting perigdle.testiag of US`T secondary containment .systems., Use the <br />appropriate pages of this form to report results for all components tested 7lre completed form, written test procedures, and <br />printoutsfr�om tests (if applicable), should be provided to the facilily. ownerloperator for submittal to the 'local regulatory agency, <br />.1. FACILITY rNFORMATFON <br />Facility Name: Date ofTestini <br />Facility Address: C L O0. <br />Factlk[ Contact: Pharte: <br />Date 'Local Agency Was Notified of Testing. S8999 - <br />Name of Local Agency inspector (aj'present during testing): <br />2. USTING CONTRAC.TOPE INFORKAT <br />Company Nerhe: ABLE Malntensnee, Inc, <br />Technician Conducting Test: Mike Trejo I.C.C. # 5252033 -UT <br />Credentials: 0 CSLB Licensed Conttactor D S WFtCB Licensed Tank Tester <br />LicenSe;"Fype:'Ap B,.iaz., CIO Licenlagse Number: 312844 <br />Manufacturer Trainln <br />Manufacturer component(s) <br />AvaiiaW upon request <br />3. SUMMARY OF TF,RT RMWILTR <br />if hydrostatic testi6g was performed, describe what was clone with the water after completion of tests: <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONJDVCTING THIS TESTING <br />To the best of my knowledge, the facts stated in this doeunrent are accurateand bz full; compliance with legal requiremmenis' <br />Technician's S e.:— _ _ \ %� Date_ -1*–& <br />i <br />I <br />i <br />i <br />I CHI <br />6 <br />if hydrostatic testi6g was performed, describe what was clone with the water after completion of tests: <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONJDVCTING THIS TESTING <br />To the best of my knowledge, the facts stated in this doeunrent are accurateand bz full; compliance with legal requiremmenis' <br />Technician's S e.:— _ _ \ %� Date_ -1*–& <br />