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JAN -20-2009 09:33 Service Station Systems 408 938 ee88 P.02 <br />y <br />Secondary Containment Testing Report Form <br />This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the <br />appropriate, pages of 1his form to report results for all components tested The completed form, written test procedures, and <br />printouts from tests (if. applicable); should be provided to the facdiry owner/operator for submittal to the local r&gulatuty agency, <br />1• FACILITY INFORMATION <br />Facility. Name:: 2Ci���� Date ofTesting:V2—aio 08 <br />Facility..Address: ka0.�✓Lk —r <br />Facility Contact; Phone: 4 <br />Date Local Agency Was Notified of Testing: µ 0989— 3yr. Compliance.'rest <br />Mame of Local Agency Inspector (if present during testing): <br />2. . TESTING CONTRACTOR INFORMATION <br />Company:Nwe: ABLE. Maintenance, Inc. _ <br />Technician Conducting Test:.Iames Moore / I.C.C. #5254517 -UT Elodio Sanchez / I.C,C. #5313877 -UT <br />Credentials, M CSLB Licensed Contractor ❑ SWRCB Licensed Tank Tester <br />License Type; A, B, Haz., C10 License Number: 312844 <br />Manufacturer_Tra fining <br />Manufacturer Component(s) w Date Training lrxhires. <br />Available upon realuest <br />3. <br />SiIMMARV Orq TFCT UVIZITY Tc <br />Cam,ponent; <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />Notcs: <br />Tank Annular 2 <br />Q _ <br />❑ <br />Cl <br />" <br />Secondary Pipe . <br />D <br />fa <br />❑i <br />L�..r,dt�„�y'iott osf <br />❑ <br />n <br />❑ <br />0 <br />Turbine Sump. - -M, <br />fi <br />, <br />❑ <br />_D <br />CI <br />0 <br />0 <br />p <br />UDC - E Or <br />❑ <br />C� <br />❑ <br />. <br />Fill Sump <br />'iL-k- <br />❑ <br />❑ <br />❑ <br />❑ <br />,�,� -rte/ ��.J,_ �,� <br />TLM Sump - <br />❑ <br />❑ <br />__-t <br />C <br />C <br />❑ <br />C! <br />S.pill.Bucket - to <br />D <br />❑ <br />❑ <br />� <br />If hydrostatic testing wasperformed, describe what was done with the water after completion of tests: <br />CEATI:Fi.CATIOIV OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS Tri STING <br />To the best of my knowledge, a jocts stated in this doca??wnt are accurate and in fuh compliance with legal requirammis <br />Techxtician's S:igpat <br />