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MA`s'-28-2018 19:52 Service Station Systems 408 938 8888 P.03 <br /> r <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 ogenry, <br /> 1. FACILITY INFORMATION <br /> Facility Name: V r,P► I Date of Testin :I} 11b /)'0 <br /> Facility Address: 2+4 k V- Wrr M0-01 t.xft 01 C-tsl� <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified ofTesting: SB989- <br /> Name of Local Agency Inspector(if present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: ABLE Maintenance,Inc. <br /> Technician Conducting Test: 7GLopto 6P1Qg±V C,�' ' 5 3$1"7-U <br /> Credentials: Z CSLB Licensed Contractor 0 SWRCB Licensed Tank Tester <br /> License Type:A,B,Haz.,CIO License Number: 312844 <br /> Manufacturer Trainine <br /> Manufacturer Com onent s Date Training Expires <br /> Available upon request <br /> 3. SUMMARY OF TEST RESULTS <br /> Component: Pass Fail Not Repairs Notes: <br /> Tested Made <br /> Tank Annular - ❑ ❑ ❑ ❑ <br /> C1 ❑ r � <br /> Secondary Pipe ❑ ❑ ❑ ❑ <br /> ❑ o i D D <br /> Turbine Sump - ❑ ❑ D E. <br /> UDC - ❑ ❑ 0 ❑ <br /> Fill Sump - k-7 ❑ ❑ CJ M <br /> ❑ 0 D ❑ <br /> TLM Sump - ❑ D D ❑ <br /> ❑ D D D _ I <br /> Spill Bucket - 0 0 D k <br /> D o o a <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> CERTIFICATION OF TECHNICIAN RFSPONSIRI,I+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:0 `" Date: 4-' �' l� <br />