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UNDERGROUND STORAGE TANK <br /> SECONDARY CONTAINMENT TESTING REPORT FORM (Page 6 of 6) <br /> XXIe UNDER-DISPENSER CONTAINMENT TESTING INFORMATION <br /> Manufacturers IdentifyUDC ID from Section III for each Manufacturer <br /> Western Fiberglass 1 V 2 ❑✓ 3 ❑✓ 1 4 © 5 © 1 6 ❑ <br /> 7 ❑ 8 ❑ 9 ❑ 1 10 ❑ 11 ❑ 12 ❑ <br /> 1 ❑ 2 ❑ 3 ❑ 1 4 ❑ 5 ❑ 6 El <br /> El Ll9 LJ10 ❑ 11 ❑ 12 ❑ <br /> Test Method Used : ❑ Manufacturer Guidelines (Specify) : <br /> ® Industry Code or Engineering Standard (Specify) : Hydrostatic <br /> ❑ Engineered Method (Specify): <br /> # of Attached Pages <br /> Attach the testing procedures and all documentation required to determine the results. <br /> UDC Testing Training and Certifications (List applicable certifications) Expiration Date <br /> ICC UST Certification # 5254516 7/ 12/2021 <br /> INCON TS-STS L4 - Certification # 1012573708 1 /27/2020 <br /> XXII , COMMENTS <br /> Provide any additional comments here. <br /> UDC 1 /2 disassemble plumbing to adjust and tightened penetration boots , retested and passed . <br /> UDC 3/4 , 5/6, 7/8, 9/ 10 replaced penetration boots , test boots and installed jumper lines . Retested and passed , <br /> i <br /> i <br /> I <br /> E <br /> E <br /> If the facility has more components than this form accommodates, additional copies of these pages may be attached. <br /> UDC = Under-0ispenser Containment; ID = Identification <br />