Laserfiche WebLink
MAR-23-2010 09:52 Service Station Systems 408 938 8888 P.03/11 <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 completed form, written test procedures, and <br /> printouts from tests (if applicable), should be provided to tha facility owner/operator for submittal to the local regulatory agency. <br /> I. FACILITY INFORMATION <br /> Facility Name: Safeway#2707 Date of Test ng: 2/23/10&2/23/10 <br /> Facility Address: 6425 N Pacific Ave—Stockton CA 95207 <br /> Facility Contact: Phonic <br /> Date Local Agency Was Notified of Testing, SB989—3yr.Compliance Test <br /> Name of Local Agencv Inspector(f 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 Elodio Sanchez ICC#5313877-UT <br /> Credentials: ® CSLB Licensed Contractor 7 SWRCB Licensed Tank Tester <br /> License Type:A,B,Itam,CIO License Number: 312844 <br /> Manufacturer Train'n <br /> Manufacturer <br /> Component(s) Date Training Expires <br /> Available upon request <br /> 3, SUMMARY OF TEST RESULTS <br /> Not Repairs Not Repairs <br /> Component: Pass Pail Tested Made Component: Pass Fail Tested Made <br /> 87 Tank:n1jaWr <br /> ❑ ❑ ❑ UDC 5/6 © ❑ G ❑ <br /> 9I/Diese ❑ ❑ ❑ UDC 7/8 © ❑ ❑87-A Se ❑ ❑ ❑ UDC 9/1087-B Se ❑ ❑ ❑ UDC 11/12Q ❑91- A Se ❑ ❑ ❑ UDC 13/1491-B Se ❑ ❑ ❑ UDC 15/16 ❑ ❑ ❑ <br /> DSL- A Seconda ❑ ❑ ❑ 87 FillSump ❑ © ❑ ❑ <br /> 9l Fill Sump <br /> E) ® ❑ ❑ <br /> DSL-B Secondary Product II El 11 [1 <br /> ❑ ❑ <br /> 87 Vent ® ❑ ❑ ❑ Diesel Fill Sump ❑ <br /> 91 Vent ® ❑ ❑ ❑ Vent Sump MI ❑ ❑ ❑ <br /> Diesel Vent <br /> ® 13 ❑ [1 Spill Buckets ❑ ❑ ❑ <br /> 87 Turbine Sump ff] ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 91 Turbine Sump M ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Diesel Turbine Sump ® ❑ ❑ I ❑ ❑ ❑ ❑ <br /> UDC 1/2 ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> UDC 3/4 0 ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> Used pump test truck <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,the facts stated in tills document are accurate and in full compliance with legal requirements <br /> Date: 2/23/10&2/24/10 <br /> Technician's Signature: <br />