Laserfiche WebLink
MAY -07-2009 11:01 Service Station Systems <br />408 938 8888 P.02 <br />Secondary Containment Testing Report Form <br />This frrn is intender) for usa by corrtr•adors pe{rorrning periodic testing of USTsecondary containment systems. Use rhe <br />oppropriate pages of this form to report results for all cnrnpunents tested The completed form, wrltfen test procedures, and <br />printotaw/;•um tests (if applicable), ihoidd be provided to lhefacilily vyvner/operator jar submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />�H'acili[y Vame:' �� 16>0 .Date of Testing: <br />j Facility Address:" `�� "� c _` �; -.�_ r ej <br />-- _�"`fC <br />1 Facility contact: T� _ Phone: <br />li Date Local Agency Was Notified of Testing : SB989 – i <br />P Nance of Local Agency Inspector (ifpresent during testing); <br />2• TESTING CONTRACTOR INFORMATION <br />ii Cotnpany Name: ABLE Maintenance, Inc, <br />Pass <br />1'echnician Conducting Test: Marc Tillotson I.C.C. # 5252035 -UT - - <br />Credentials: ® CSLl3 Licensed Contractor <br />U SWRCS Licensed'fank Tester <br />i License 'l'ype' A. 8, Hnz., CIO <br />License Number,. 312844 <br />Manufacturer <br />Manufacturer Trainine <br />Companent(tis) Date Training Expires <br />m <br />Avitilable upon request <br />_ <br />FJ J <br />7 <br />'J <br />2 <br />3. SUMMARY OF TEST RESULTS <br />Component: <br />Pass <br />;rail <br />Not <br />Tested <br />Repairs <br />Made <br />Notes: <br />r Tank Annular <br />!7 <br />i7i <br />FJ J <br />7 <br />'J <br />2 <br />^� <br />I <br />Secondary pipe <br />-- <br />.. <br />_ <br />... ' 'PX_N '11r x` 11 q k S <br />�fUrbineS=p 'L <br />l� <br />_N,�.�e >4 O'M *UXM <br />1-1 <br />C <br />C <br />Cti>ctg <br />8'� <br />� UDC— <br />�❑ <br />❑ <br />lr N <br />J <br />o <br />❑ <br />❑ <br />o C�*-bzi <br />__ <br />Fill Sump w <br />i__..._,_.. <br />E <br />L-2� <br />-Awu 't 100 %. <br />t <br />�I <br />❑ <br />U <br />❑ <br />iA..No r-vI <br />_ <br />I'I.M Sump _ <br />_� <br />C <br />L7 <br />0 <br />CW -_Q1 L� e�t ilk-, <br />Spill 'Bucket <br />-� <br />❑ <br />17 <br />❑ <br />It hydrostatic testing was performed, describe what was done with the water after completion of tests - <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING TIIIS TESTING <br />To the hest of itty knowledge, thefrets stetted in this document are accurate and in fail compliance wit/t legal requirements <br />- —,cp, <br />Technician's 5ignitz.u•e��� -�-.--:;,• <br />_-, Date: � � I _ <br />01 <br />