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SEP -10-2009 14:24 Service Station Systems 408 938 8888 P.02 <br />, <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 ,ofthis form to report results for all components tested. Me compleiedform, written test procedures, and <br />printouts from tests (ifapplicable), should beprovided to the facility owner/operator for submittal to the local regulatory agency. <br />1. <br />FACILITY INFORMATION <br />Facility Name: yj Lk,4 7p Date of Testing: / o / Oq <br />Facility Address:C t% L1 — 01 <br />Facility Contact: Phone: <br />Date Local Agency Was Notified of Testing; SB989 — <br />Name of Local Agency Inspector (ifpresent during testing): <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: ABLE Maintenance, Inc. <br />Pass <br />Technician Conducting Test: Marc Tillotson 1. C. C. #5252035 -UT <br />Credentials: to CSLB Licensed Contractor <br />0 SWRCB Licensed Tank Tester <br />License Type: A, B, Haz., C10 <br />Tank Annular - <br />License Number. 312844 <br />Manufacturer <br />Manufacturer Trainine <br />Com nen s Date Training Expires <br />Available u on re nest <br />3. <br />SUMMARY OF TEST RESULTS <br />Component: <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />Notes: <br />Tank Annular - <br />❑ <br />❑ <br />❑ <br />❑ <br />Secondary Pipe - <br />❑ <br />❑ <br />❑ <br />❑ <br />� <br />Turbine Sump - <br />❑ <br />❑ <br />❑ <br />❑ <br />— <br />❑ <br />0 <br />❑ <br />❑ <br />UDC - 2 <br />❑ <br />❑nh�(Nut <br />�'J 2tSPl�lt2 �S Ca <br />❑ <br />❑ <br />❑ <br />0 <br />UP c— <br />Fill Sump <br />q <br />❑ <br />0 <br />❑ <br />❑ <br />❑ <br />❑ <br />0 <br />TLM Sump - <br />C <br />1 ❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Spill Bucket - <br />❑ <br />❑ <br />❑ <br />0 <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <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 full compliance wilt legal requiremenn, <br />Technician's Signature: ��/ w�� ,�~ Date: lc OGt <br />