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v <br />This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the <br />appropriate pages ofthis form to report results for all components tested! The completedform, written test procedures, and <br />printouts from tests {rf applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />Facility Name: t"` t d, "" \ Date of Ter <br />Facility Address: <br />-Facility Contact: Phone: <br />Date Local Agency Was Notified of Testing: SB989 <br />Name of Local Agency Inspector qf present during testings: �, 1` � <br />TESTING OR INFORMATION <br />Com any Name: AB intensnee, Inc. <br />Technician Conducting Test: James Moore L C.C. # 5254517 -ITT <br />Credentials: 0 CSLB Licensed Contractor <br />D SWRCB Licensed Tank Tester <br />License Type: A, B, Haz, Cid <br />rt ..._.,...: ._ ...... <br />Manufacturer <br />License Number: 312844 <br />..:,.... . <br />Mang{ tc urer Tralnin$ <br />Com nen s Date Training Expires <br />Available upon request <br />11 XWO <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, the facts stated in this document are accurate and in full compliance with legal requirements <br />Technician's Signature° Date: _=51/1 A'5' <br />111IR TOF TEST 1W <br />SULTS <br />11 XWO <br />Secondary Pipe - <br />�WAH■ 4 <br />• Bucket <br />WWI <br />"A <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, the facts stated in this document are accurate and in full compliance with legal requirements <br />Technician's Signature° Date: _=51/1 A'5' <br />