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0 <br />• <br />Secondary Containment Testing Report Form <br />R LE: Ct E i V E <br />1 20"7 <br />This form is intended for use by contractors performing periodic testing of UST secondary containment systems, s�t'�ien� r,.{ <br />appropriate pages of this form to report results for all components tested The completed form, written test procedu)W, any T`�`' `'r" <br />printouts from tests (if applicable), should be provided to the facility own erloperatorfor submittal to the local regulatory agency. <br />FArTYTrV 1N14n12MATrnW <br />Facility Name: Date of Testing: '/I i 11� 7 <br />Facility Address: <br />LC <br />Facility Contact <br />7CPhone: Cj.-'93(0- 4 O <br />Date Local Agency Was Notified of Testing: 3 -k(D ` r, <br />0989 - 3 yr. Compliance <br />Name of Local Agency Inspector (rf present during testing): <br />License Type: A, B, Haz., C10 <br />2. WRTING rnl Ti2ArTni2 TNWnAMATTnV <br />Company Name: ABLE Maintenance, Inc. <br />Technician Conducting Test: Shawn Sbragla / LC.C. # 8307967 <br />`-`— <br />Credentials: ® CSLB Licensed Contractor <br />D SWRCB Licensed Tank Tester <br />License Type: A, B, Haz., C10 <br />License Number: 312844 <br />�IullllfontnrerT'�fli',SiT, <br />Manafactwer <br />Components) <br />Date Training E_ xpires <br />Available upon request _ <br />i <br />I <br />Kj <br />gIIM vYA32V nTi TFCT 'DVV.TTT Tc <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 ofmy knowledge, the facts stated in this document are accurate and in full compliance with legal requirements <br />Technician's Signature Date:l t—` - <br />i <br />i <br />Seconduy Pipe <br />II <br />I <br />UDC <br />Sump ej <br />■ <br />!#�'� <br />t <br />is <br />SpiU Bucket <br />■ <br />■ <br />■ <br />r <br />L <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 ofmy knowledge, the facts stated in this document are accurate and in full compliance with legal requirements <br />Technician's Signature Date:l t—` - <br />