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tlJCT-25-2013 14:45 Service Station Systems 408 938 8888 P.03 <br /> rIVED <br /> OCT 25 2013 <br /> 1.FACILITY INFORMATION <br /> Facility Name. Rancho San Miguel Market Date ofTening. "1y3;/ B L <br /> Facility Address: 1409 S.Airport Way HEALTH DEPART. ,T <br /> Facility Contact phone., (209)942-2840 <br /> Date Local Agency Was Notified of Testing:9/18/13 SB989—Syr.Compliance Test <br /> Name of Local Agency Inspector(if present during testing): <br /> 2. TESTING CONTRACTOR INFORIMA'ITION <br /> Company Name:ABLE Maintenance,Ino. <br /> Technician Conducting Test: ,carnes Moore i I.C.C.#1.5254517-t11' <br /> Credentials: CSLB Licensed Contractor 7 SWRC13 Licensed Tank Fester <br /> License°type:A,13,Hoz.,C10 Licensc Number: 312844 <br /> )Manufacturer Training <br /> Manufacturer Com oncnt(s Date TraininE Expires <br /> Available upon request <br /> 3. SUMMARY OF TEST RESULTS <br /> Component: Pass Fail Not Repairs Component: Pass Fail Not Repairs <br /> Tested Made Tested Made I <br /> f <br /> 87/91 Tank Annular O ❑ ❑ p <br /> 87 Secondary Product Eli D 0 0 <br /> 91 Secondary Product C! 0 ❑ <br /> Vent Secondary Product ® ❑ C <br /> Vapor Secondary Product ® ❑ ❑ ® j <br /> 87 Turbine Sump [� ❑ ❑ i <br /> 91 Turbine Sump ® ❑ L C <br /> UDC 1/2 ♦ ❑ 1 ❑ <br /> UDC 3/4 Cil E ❑ ❑ <br /> UDC 5/6 D ❑ ❑ ❑ <br /> 87 Fill Sump E ❑ 0 0 <br /> 91 Fill Sump Em ❑ ❑ ❑ <br /> i <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> Used pump test truck <br />