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MAR-23-2010 09:52 Service Station Systems 408 938 8888 P.02/11 <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 of this form to report results for all components tested. The eomp/etedform, written test procedures, and <br /> printouts from tests(f applicable), should be provided to the focility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Date ofTestin :?- 94/ 10 <br /> Facility Address: <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing: SR989-3 yr, Compliance <br /> Name of Local Agency Inspector(ifpreseni during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: ABLE Maintenance,Inc. <br /> Technician Conducting Test: James Moore/I.C.C.445254517-UT Elodio Sanchez/I.C.C.#5313879-UT <br /> Credentials: CD CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester <br /> License Type:A,B,Haz.,CIO License Number: 312844 <br /> Manufacturer Training <br /> Manufacturer Com anent s) Date Training Expires <br /> Available upon request <br /> 3. SUMMARY OF TEST RESULTS <br /> Component;, PassFail Not Repairs Notes: <br /> Tested Made <br /> Tank Annular - 2. ❑ ❑ ❑ _ <br /> C ❑ ❑ Cl <br /> Secondary Pipe - ❑ ❑ O <br /> ❑ ❑ ❑ ❑ <br /> Turbine Sump 2" ❑ ❑ ❑ <br /> ❑ ❑ C <br /> UDC - 9f) ❑ ❑ ❑ <br /> Fill Sump -?� - ❑ ❑ ❑ <br /> C7 Q ❑ ❑ <br /> TLM Sump - p q p <br /> Spill Bucket - -5-> C ❑ 5 U <br /> ❑ ❑ ❑ C7 <br /> If hydrostatic testing was performed,describe what was dune with the water after completion of tests: <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best ofmy knowledge,Ute facts stated in this document are accurate and In full conopllauce with legal requirements <br /> Technician's Signature:. __ �' Date: -2:0 <br />