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b MPI -09-2011 08:08 Service Station Systems 408 938 8888 P.02 <br />0 0 <br />Secondary Containment Testing Report Form <br />chis jornt is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the <br />appropriate pages of this farm to report results for all components tested rhe completed form, written test procedures, and <br />printouts from tests Of applicable). should be provided to the facility ownerloperalor for submittal to the tocol regulatory agency. <br />1. <br />FACILITY INFORMATION <br />Facility Name: e' •r r?�, �"" Date ofiestin . / 1 <br />Facility Address: `5j } J ^� Lv"`. , ir�.rC <br />Facili=y Contact: <br />Phone: <br />Date Local Ag icy Was Notified of Testing : <br />SB999 — <br />Name of Local Agency Inspector (,f preverm daring resting): �. <br />ManufacturerTrainine <br />Com onent s Date Training Expires <br />2. TESTING CONTRACTOR INFORMATION <br />C:onipzny Name: ABLE Maintenance, Inc. <br />p Techntcian Conducting Test: Marc Tillotson I.C.C. 95252033 -UT <br />Credentials: 2 CSLB Licensed Contractor <br />0 SWRCB Licensed Tank Tester <br />_ <br />License Type: A, B, Hai., CIO <br />— license Number: 312844 <br />Manufacturer <br />ManufacturerTrainine <br />Com onent s Date Training Expires <br />Available upon request <br />3. <br />SUMMARY OF TEST RESULTS <br />I� <br />MM <br />OLD <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />CERTIFICATION OFTECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />ro the best of my knowledge, t/te facts stated in this document are trccurate and in full compliance with legal requirements <br />Technician's Signature: �"' gate: <br />