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MAY-27-2811 17:30 Service Station Systems 408 938 8888 P.02 <br /> Secondary Containment Testing Report Form <br /> This form is Intended for use by contractors performing periodic testing of UST secondary containment systems. Use rhe <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 facillry owner/operator far submittal to the local regulatory agency. <br /> I• FACILITY INFORMATION <br /> FFacility <br /> acility Name: Q,�' g Date of Testittg; / // <br /> acility Address; S2 <br /> Contact: Phone: <br /> Date Local Agency Was Notified of Testing: 1 t SB989- ! - <br /> Name of Local Agency inspector(fpresent during toting): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name-ABLE Maintenance,Inc. <br /> Technician Conducting TW: Marc Tillotson I.C.C.#5252035-UT <br /> Credentials: 0 CSLB Licensed Contractor D SWRCB licensed Tank Tester <br /> License Type:A,B,Rm,C10 License Number. 312844 <br /> Manufacturer Training <br /> Manufacturer Compment(s) Date Training Expires <br /> Available upon request <br /> 3. SUMMARY OF TEST RESULTS <br /> Component; Pass Fall Not Repairs Notes: <br /> Tested I Made <br /> Tank Annular - D 0 0 0 <br /> a ❑ D ❑ <br /> Secondary pipe - p 0 ❑ ❑ <br /> 0 0 0 0 <br /> Turbine Sump - a ❑ p CoOaAT Ubcir5 N <br /> ❑ a o aat 14-P t 05a. STP !!5 <br /> UDC - ❑ 71 1P"q ,3%5L ` e\-,Tp <br /> D ❑ ❑ ❑ bt&L mvio A I siii <br /> Fill Sump - ❑ ❑ ❑ D <br /> a ❑ ❑ ❑ <br /> TLM Sump - ❑ ❑ ❑ p <br /> D 0 0 0 <br /> Spill Bucket - ❑ ❑ D q <br /> 0 0 ❑ ❑ <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 Ibis document are accurate and in hell canpllance with legal requirements <br /> Technician's Signature: __ - Date: Z <br />