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0 <br /> OCT-5-2213 14:45 Service Station Systems 408 938 eeee P.02 <br /> • '� RECEivEO <br /> Secondary Containment Testing Report Form P r T 25 ?n13 <br /> This firm is intended fOr use by contractors performing periodic testing of M7 secondary containment systems, Use the <br /> approprlote pages of thisform to report results far all aampoments tested The completedformg, written test procedures, acid I <br /> printouts from to#ti(if applicable),should he provided to the facility awnerfoperator for submittal to the local,regulatory agency, <br /> X+ FACILITY DWORMATION <br /> Facility Name: c i LrG Date of Testing:e-r rt 13 <br /> Facility Address: <br /> Facility Contest: Phoric: <br /> Date local Agency Was Notified of Testing: 9T, -1s $8999—3 yr.Compliance <br /> Name of Local Agency inspector(pfpresent during testing): <br /> 2. TES'T'ING CONTRACTOR INFORMATION <br /> Company Name:ABLE Maintenance,Inc, <br /> Technician Ccmducting Test. .lances]Moore/LC,C.#5254517•UT <br /> Credentials: 0 CSLB Licensed Conbuctar 0 SWRCB Licensed Tank Tesw <br /> Liemse Type:A,B,Ha&,CIO License N=ber: 312844 <br /> Mnaufactvrer Training <br /> mi <br /> Manufacturer Ctonen s fir <br /> Date Trainin Ex es <br /> Available upon request <br /> 3. SCARY OF TEST RESULTS <br /> companefty Faso sit Nat Repairs Nates: <br /> Tested Made <br /> Tank Annular - i ❑ D ] <br /> Secondary Pipe - 4 -;z- V?-A--z <br /> C3 ❑ ❑ Grp <br /> Turbine Sump - "L o n ❑ ❑ <br /> 0 . 11 ❑ 11 <br /> UDC - Q ❑ 0 <br /> ❑ 0 0 ❑ <br /> Fill Sump WO ❑ ❑ ❑i <br /> ED 0 ❑ ❑ <br /> T'LM Sump - ❑ 1 p ❑ ❑ ► ; .J <br /> ❑ 0 - 0 ❑ <br /> Spill Bucket - ❑ ❑ ❑ ' <br /> U a ❑ ❑ <br /> If hydrostatic testing was perfomed,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 lily knawle4e,the fit .started in this dtecument are accormre and in,full compliance with legal requirentmis <br /> Technician's Signature: Date:— --- <br /> r <br />