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MAY,-06-2011 22:4e Service Station Systems 408 938 8888 P.02 <br /> Secondary Containment Testing Report Form <br /> This Jorar is inlended for use by contractors performing periodic testing of UST secondary containment systems. Use the <br /> appropriale pages of this form to report results for all components tested rhe completed form, written test procedures, and <br /> prinloutS from tests'(if applirahle). should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> FACILITY INFORMATION _ <br /> Paciliiy Name: b,2,�` 1`}c�r"G = Date of Testing: t-{ I`� 1`� <br /> Facility Address: •��_L�����,�1�.yv�Gyt'1 <br /> Facility Contact: _ 1j Z <br /> "LNallit, <br /> Local A,ency Was Notified of Testing: SB989 <br /> of Local Agency Inspector(rfpre�sent duringlesring): <br /> Z, TESTING CONTRACTOR INFORMATION <br /> w <br /> Con <br /> ip nyName, ABLE Maintenance,Inc, <br /> Technician Conducting Test: <br /> Marc Tillotson I.C.C.45252033-UT <br /> Credentials. _0 CSLI3 Licensed_Contractor L SWRC3 Licensed Tank Tester <br /> License Type A, 0,Haz.,CIO - License Number: 312844 <br /> Manufacturerrainine <br /> Manufacturer Components Date 7rdining Ex ices <br /> Available upon request <br /> 3. SUMMARY OF TES's' RESULTS <br /> Component: Pass Fail Not Repairs 1\otesc <br /> Tested Made <br /> Tank Annular - f ❑ ❑ <br /> D ❑ 0 <br /> Secondary Pipe - n ❑ \et <br /> ❑ Q 0 r 1 <br /> Turbine Sump - ❑ 0 S - V0 <br /> UDC - ❑ �7 I ❑ 0 <br /> ❑ ❑ ❑ <br /> Fill Sump - ❑ 11 ❑ 11 <br /> ❑ ❑ D ❑ <br /> TLM Sump - 0 0 D ❑ <br /> - a n ❑ ❑ <br /> Spill Bucket - ❑ C7 ❑ 0 <br /> 0 0 C1 ❑ <br /> If hydrostatic testing was performed, describe what was done with the water after cornpledon of tests: <br /> ns— c�: oS ti <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THiS TESTING <br /> To the best of my knowledge,the facts•stared in this document are accurate anti in full contpliance with legal requiren:etrts <br /> Technician's Signature: ,� <br />