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MAY-16-2008 18:11 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 conlaimnent 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 (ifopplicable),should he provided to thefaciUly owner/operatorfor submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: 7-40-T Date of Testing; q /l /tag <br /> Facility Address: 6LMIS N, <br /> FacilityContact: Phone: 7 14 Z_ <br /> Date Local Agency Was Notified of Testing: SB999-3 yr.Compliance <br /> Name of Local Agency Inspector(iJpresent during testinz): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name:ABLE Maintenance,Inc. <br /> Technician Conducting Test: Marc Tillotson I.C.C.#52$2035-U1 <br /> Credentials: 0 CSLB Licensed Contractor n SWRCB Licensed Tank Tester <br /> License Type: A,B,Ham,C10 License Number: 312844 <br /> Manufacturer Training <br /> Manufacturer Com onent s Date Training Expires <br /> Available upon request <br /> 3. SUMMARY OF TEST RESULTS <br /> Component: Pass Fail Not Repairs Notes: <br /> Tested Made <br /> Tank Annular - ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> Secondary Pipe - ❑ ❑ ❑ ❑ <br /> Turbine Sump - ❑ SP1 ❑ 8' `$� Sz P 5 <br /> ❑ ❑ 0 ❑ air <br /> UDC - ❑ ❑ ❑ ❑ <br /> ❑ ❑ 0 ❑ <br /> Fill Sump - _ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ 11 <br /> TLM Sump - ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> Spill Bucket - ❑ z ❑ �J5 <br /> ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> t� esn��, �J•e�i`,2T(— �IJ,QrS U" <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best ofmy knowledge,the facts stated In this document are accurate and in full compliance with legal requirements <br /> Technician's Signature:_ — - Date: <br />