Laserfiche WebLink
% MAY-06-2011 22:49 Service Station Systems 408 938 8888 P.03 <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 this form to report resultsfor all components tested. The completed.form, written test procedures, and <br /> printouts from tests (if applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: SHELL/USA q 68153 1 Date of Testing: 4/8/11 <br /> Facility Address' 2448 W.Kettleman Lane—Lodi CA 95242 <br /> Facility Contact: Phone: (209)369-3124 r <br /> Date Local Agency Was Notified of Testing; SB989—Repair/Retest <br /> Name orLocal Agency Inspector ff presew during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name-ABLE Maintenance,Inc. <br /> Technician Conducting Test: Marc Tillotson ICC#5252033-UT <br /> Credentials: ® CSLB Licensed Contractor I"SWRCR Licensed Tank Tester <br /> License Type:A.B,Haz„C10 Licensc Numbcr: 312844 q <br /> W ?il <br /> Manufacturer Trainins <br /> Manufacturer Component(s) Date Training E.x.fres <br /> Available upon request <br /> 3. SUMMARY OF TEST RESULTS <br /> Component: Pass Fail Not Repairs Component: Pass wait Not Repairs <br /> Tested Made Tested Made <br /> 87 Secondary Product Cil ❑ ❑ ❑ ❑ ❑ ❑ <br /> 89 Secondary Product ® ❑ ❑ ® ❑ ❑ D ❑ <br /> 91 Secondary Product ® ❑ ❑ ® ❑ 0 ❑ ❑ <br /> 87 Turbine Sump ® 1 0 1 ❑ ® I ❑ ❑ ❑ ❑ <br /> 89 Turbine Sump ❑ W ❑ ® ❑ D ❑ ❑ <br /> 91 Turbine Sump ❑ Chi ❑ CX] ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ D D ❑ D <br /> ❑ ❑ ❑ ❑ ❑ Eli] El 11 <br /> ❑ ❑ a o ❑ ❑ ❑ Cl <br /> ❑ a o o I ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ o <br /> ❑ ❑ ❑ ❑ ❑ ❑ D ❑ <br /> ❑ ❑ ❑ ❑ D D ❑ ❑ <br /> El El ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ D ❑ ❑ ❑ <br /> D D ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> Pump test truck used for testing <br /> CERTIFICATION OF TECHNICL4,N RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,the facts stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: Date:4/8/11 <br />