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Secondary Containment Testing Report Form <br />This form is intended for use by contractors performing periodic testing of UST secondan, containment systems. Use the <br />appropriate pages of this form to report results for all components tested. The completedform, written test procedures, and <br />printouts from tests (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />tFACILITY INFORMATION <br />Facility Name = = t- t ( <br />Date of Testing: 1 Izy 14 <br />Facility Address: 2 4 4 e—, vv L t"i 1= ►-••� -- L <br />t �U.l `d t rte? �I/ <br />Facility Contact: <br />Phone: <br />Date Local Agency Was Notified of Testing: <br />SB989 - 3 yr. Compliance <br />Name of Local Agency Inspector (:f present during testing); <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: ABLE Maintenance, Inc. <br />Technician Conducting Test: .lames Moore / I.C.C. #5254517 -UT <br />Credentials: ® CSLB Licensed Contractor <br />0 SWRCB Licensed Tank Tester <br />License Type: A, B, Haz., CIO.License Number: 312844 <br />;� --va .. r. y :r,.,.. y'_`..n...-.-. �..�;r�":.'x'y"''_.�-„T_«.�t::."'^- ;..�C t�...• ... L....-.�-r....: "'"'^. ��."'�:..+T�:;:.� ."y .:�.,,...., <br />Manufacturer Training <br />_ Manufacturer Component(s) Date Training Expires <br />Available upon request <br />3. SUMMARY OF TEST RESULTS <br />10111 If I III] I U4 It <br />I Awls Int <br />�®�0 <br />� F ■ � � / �;� jam. <br />• <br />0' <br />- • , ,,' Lam; <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, th acts stated In this document are accurate and In full compliance with legal requirements <br />Technician's Signatur • Date: <br />