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FEE-25-2011 15:36 Service Station Systems 402 938 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 results for 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 /> I. FACILITY INFORIMATION <br /> Facility Narne: I Datc of Testin : ) I-e I1 <br /> Facility Address:24q.-. W. <br /> Facility Contact: r Phone: <br /> Date Local Agency Was Notified of Testing: SR989—3 yr. Compliance <br /> Name of Local Agency Inspector(if present during testing): <br /> 2, TESTING CONTRACTOR INFORMA710N <br /> Company Name:ABLE Maintenance,Inc. _ <br /> Technician Conducting Test: James Moore/I.C.C.X5254517-UT __�-� <br /> Crcdentials: 0 CSLB Licensed Contractor ❑SWRCB Licensed Tank`fester <br /> License Type:A, B,Haz,,CIU License Number: 312844 <br /> Manufacturer Training <br /> Manufacturer component(s) Date Training Expires <br /> Available u on re uest <br /> 3. SUMMARY OF TEST RESULTS <br /> Component: Pass rail Not Repairs Notes: <br /> Tested Made <br /> Tank Annular - :7' _ ❑ ❑ <br /> Secondary Pie -11l <br /> Turbine Sump - -;27 ❑ ( ❑ v+��.-� s=r,� <br /> UDC <br /> ❑ ❑ ❑ ❑ <br /> Fill sump - '1 ❑ ❑ ❑ - <br /> TLM Sump -1 _�.. .�. ❑ ❑ ❑ ❑ <br /> Spill Bucket - L" ❑ ❑ ❑ _ j <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,the facts stated In this document are accurate and In full compliance wish legal requirements <br /> Technician's Signature: Date:" /_z�l <br />