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SEP-25-2008 12:55 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 USrsecondary,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 /> pr/ntouts from tests(if applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITYINFORMATION <br /> Facility Name: Date of Testis : / �! <br /> Facility Address: Gus?,—j - 2 ,1 E slit 0� <br /> Facility Contact phone: Q cxz) <br /> Date Local Agency Was Notified of Testing; SB989- <br /> Name of Local Agency Inspector(efpreseni during testing): <br /> 1. TESTING CONTRACTOR INFORMATION <br /> Com any Name:ABLE Maintenance,Inc. <br /> Technician Conducting Test: Marc Tillotson I.C.C.#5252035-U1 <br /> G edentials: R CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester <br /> License Type: A,B,Raz.;CIO License Number: 312844 <br /> Manufacturer Trainine <br /> Manufacturer Component(s) Date Traininp Expires <br /> Available upon request <br /> 3. SUMMARY OF TEST RESULTS <br /> Component: Pass Fad Not Repairs Notes: <br /> Tested Made _ <br /> Tank,Aunular - ❑ ❑ ❑ ❑ <br /> Secondary Pipe - ❑ ❑ ❑ ❑ <br /> TuibineSurnp 1DO-OV PILING poval <br /> ❑ 0 ❑ CJ a&UPC ONOO I Tv 67 <br /> UDC - .�_.W�. _• �._ _... ❑ ❑ <br /> o 0 ❑ ❑ a vo <br /> Fill Stump - ❑ ❑ 0 0 <br /> ❑ 0 0 0 <br /> TLM Sump - __._._.�,... ❑ . �. ._...❑...._ -_. ❑...... <br /> Spill Bucket - 2 0 ❑ ❑ rWWW DUST <br /> ❑ ❑ ❑ ❑ 4 q 1 Flu- <br /> If hydrostatic testing was performed describe what was done with the water after completion of tests: <br /> CERTIFICATION OF TECI3NICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,the facts stated in slits document are accurate and infill compliance with legal requirements <br /> Technician';Signature: �r�/��'`�—�`' ___ Date: O <br />