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W I <br />HLGEIVE . <br />MAR 2 3 2015 <br />(NVIRONMENTA? <br />Secondary Containment Testing Report Form <br />This farm is intended far use by contractors performing periodic testing of UST secondary containment systems. Use the <br />appropriatePages ofthisforat to report rrsultsfor all components tested. The comp/etedform, written testprocedures, and <br />printours from tests Afapplicable), should be provided to the facility owner/operator for submittal to the local regulatory agency, <br />1 FacilityName: .�A Wi4 L/ Z��'J Date of Testing: Z /Z7 / /S' <br />IFacility Address: Gg2J— 74-6 rr <br />reetury wnmcc • ` cto r-K� -s`6U - b`l � J <br />Date Local Agency Was Notified of Testing : SB989 _ r <br />Name of Local Axency Inspector ftfaresent during testing): irii r y dL .s <br />2. <br />TESTING CONTRACTOR MMUMATInt r <br />Company Name: ABLE Maintenance, Inc - - - - - — - --- — --- <br />Technician Conducting Test: Nick Andrews I.C.C. 118180923 <br />Credentials: 0 CSLB Licensed Contractor 0 SWRCB Licensed Tank Tester <br />License Type: A, B, Haz., C10 I License Number. 312844 <br />Manufattorer TY .A n<ng <br />Manufacturer Component(s)Dau Ttaiain Ex ices <br />Available upon request <br />3. <br />SUMMARY OF TEST RESULTS <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />CERTIFICATION OF TECHNICIAN RESPONSHiLE FOR CONDUCTING THIS TESTING <br />re the best of my knowledge, the faces sorted in this document are accurate and in full compliance with legal requirements <br />Technician's Signature:-J�l T', r��� Date: �`r%7•�J <br />nnoo <br />� <br />o©aoI <br />norms© <br />� <br />onoo <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />CERTIFICATION OF TECHNICIAN RESPONSHiLE FOR CONDUCTING THIS TESTING <br />re the best of my knowledge, the faces sorted in this document are accurate and in full compliance with legal requirements <br />Technician's Signature:-J�l T', r��� Date: �`r%7•�J <br />