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UNDERGROUND STORAGE TANK <br /> SECONDARY CONTAINMENT TESTING REPORT FORM ( Page 6 of 6) <br /> XXI . UNDER-DISPENSER CONTAINMENT TESTING INFORMATION <br /> Manufacturers ldentifNyUDC ID from Section III for each Manufacturer <br /> 1 2 Z3 � 4 ❑ 5 ❑ 6 El <br /> Fiberglass/ Polymer 7 ❑ 8 ❑ 9 ❑ 1 10 ❑ 11 ❑ 12 ❑ <br /> 1 ❑ 2 ❑ 3 ❑ 1 4 ❑ 5 ❑ 6 ❑ <br /> 7 ❑ 8 ❑ 9 ❑ 1 10 ❑ 11 ❑ 12 ❑ <br /> Test Method Used : ❑ Manufacturer Guidelines (Specify) : <br /> ❑ Industry Code or Engineering Standard (Specify) : <br /> 0 Engineered Method (Specify) : Caldwell Systems/ Hydrostatic 30 Minutes <br /> # of Attached Pages <br /> Attach the testing procedures and all documentation required to determine the results. 2 <br /> UDC Testing Training and Certifications (List applicable certifications) Expiration Date <br /> Caldwell Level Change Indicator 7/5/2020 <br /> ICC Service Technician #5246802 - UT 3/20/2021 <br /> Underground Storage Tank Tester License #90 - 1120 12/31 /2019 <br /> XXII . COMMENTS <br /> Provide any additional comments here. <br /> RECEIVEL <br /> SEP 16 2019 <br /> ENVIRONMENTAL HILALHri <br /> PERMIT / SERVICES <br /> If the facility has more components than this form accommodates, additional copies of these pages may be attached. <br /> UDC = Under-Dispenser Containment; ID = Identification <br />