Laserfiche WebLink
DEC-03-2007 11:37 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 ofthisform to report resultsfor all components tested. The completedforrn, written test procedures, and <br /> printouts from rests(if applicable),should be provided to thefacility owner/openaor for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Safeway#2707 Date of Testing: 11/12/07 <br /> Facility Address: 6425 N.Pacific Ave—Stockton CA 95207 <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing : SB989—3yr.Compliance Test <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: James Moore/I.C.C.#5254517-UT <br /> Credentials: 0 CSLB Licensed Contractor SWRCB Licensed Tank Tester <br /> License Type: A,B,Haz.,C10 License Number: 312844 <br /> Manufacturer Training <br /> Manufacturer Component(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 - 2 <br /> i <br /> Secondary Pipe - 10 ® x Lines i -4 passed.5-10 tailed <br /> Turbine Sump -3 M ® Torn penetrations on all STP's <br /> UDC - 8 8 Dispcnsers't19/10,11/12, 13/14&15/16, 1-2, <br /> 5/6 failed.Valves/corduit issues <br /> Fill Sump - 3 <br /> TLM Sump - 0 m <br /> Spill Bucket - 5 © 87 vapor and 91 fill buckets failed.91 was not <br /> tcsted <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> Used test truck <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 fulf compliance with legal requirements <br /> Technician's Signature: Date: <br />