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Secondary Containment Testing Report For <br />This form is intended for use by contractors performingpertodic testing of USTsecondwy containment systems. Use the <br />appropriate pages of thisform to report results for all components tested The completed form, written test procedures, and r <br />printouts from tests (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1. <br />V i' <br />Facility Name: + Date of Testing: F l iZ- <br />Facil4Address: \Z—t 1,� Gam° a iz o <br />Facility Contact: <br />Phone: <br />Date Local Agency Was Notified of Testing: S11989 - <br />Name of Local Agency Inspector (cfpresent during testing): <br />Company Name: ABLE Maintenance, Inc. <br />Technician Conducting Test: Marc Tillotson I.C.C. # 5252035 -UI <br />Credentials: ® CSLB Licensed Contractor ❑ SWRCB Licensed Tank Tester <br />License Type: A, B, Haaz., CIO License Number. 312844 <br />ManufacturgE IMining <br />Manufacturer Ca nen s Date Training Expires <br />Available upon request <br />Ef <br />�191010' ; 01401311 a <br />If hydrostatic testing was performed, describe what was done with the water atter completion of tests: <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the beat of my knowledge, the facts stated in this document are accurate and in full compliance with legal requirements <br />,�. <br />Technician's Signature: �e T� �"'- Date:--- <br />�, _ <br />Secondary Pipe - x <br />4Spill Bucket <br />If hydrostatic testing was performed, describe what was done with the water atter completion of tests: <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the beat of my knowledge, the facts stated in this document are accurate and in full compliance with legal requirements <br />,�. <br />Technician's Signature: �e T� �"'- Date:--- <br />�, _ <br />