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DEC-03-2007 11:3? Service Station Systems 408 938 8888 P.O2 <br /> Secondary Containment Testing Report .Form <br /> This form is intended far use by contractors performing periodic testing of UST secondary containment systems. Use rhe <br /> appropriate pages ofthis forme to report results for all components tested The cotnpletedform, written lest procedures, and <br /> printouts from tests(if applicable), should beprovided to thejacithy ownar/operator for submittal to the local regulatory agency. <br /> I. FACMITY INFORMATION <br /> Facility Nain 45 ' l Date of Testing!)) IIZ/ <br /> Facility Address: � <br /> k � <br /> Facility Contact: Phone; <br /> Date Local Agency Was Notified of test ng: SB989—3yr.Compliance Test <br /> Name of Local Agency Inspector(tfpresent during testing): <br /> 2• TESTING CONTRACTOR INFORMATION <br /> Company Name:ABLE Maintenance,Inc. <br /> Technician Conducting Test: James Moore/I.C.C. 45254517-UT <br /> Credentials: ® CSLB Licensed Contractor 0 S WRCB Licensed Tank Tester <br /> License Type:A,B,Raz.,CIO License Number: 312844 <br /> Manufacturer Training <br /> Manufacturer Component(s) bate Training E ices <br /> Available upon request <br /> 3. SUMMARY OF TEST RESULTS <br /> Components Pass FailNot Repairs Nates. <br /> 'tested Made <br /> Tank Annular Etc ❑ ❑ ❑ <br /> Secondary Pipe - ❑ ❑ ❑ ba- p��+-+ w:.x �-� •-ss <br /> ❑ ❑ ❑ ❑ 1•wm*� -PNG arm <br /> Turbine Sump - ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> UDC - 0 ❑ ❑ <br /> W1 �A�bi <br /> ❑ ❑ ❑ ❑ <br /> Fill Sump - 3 ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> TLM Sump - ❑ ❑ ❑ ❑ f <br /> ❑ D ❑ ❑ <br /> Spill Bucket - ❑ ❑ QI ¢IR- <br /> ❑ ❑ 0 0 <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tcsts: <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> 1'a//is best of my knowledge.,the-facts stated in this document are accurate and in full eornp/ianee with/legal requirements <br /> Technician's Signature: Date: <br />