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JUL-09-2009 15:32 Service Station Systems 408 938 8888 P.02 Secondary Containment Testing Report Form This form is intendedfor use by contractors performing periodic testing of UST secondary containment systems. Use the appropriate pages of thisform to report results for all components tested The completed form, written test procedures, and Printouts from tests (if applicable), should be provided to rhe facility owner/operator far submittal to the local regulatory agency. 1. FACILITY INFORMATION Facility Name: W b DateofTesting: \\/ -7+/ Facility Address: t{235 f� c� Facility Contact: Phone: Date Local Agency was Notified of Testing: SE989 - Name of Local Agency Inspector (fpresent during testing): 2. TESTING CONTRACTOR INFORMATION Company Name: ABLE Maintenance, Inc. Pass Technician Conducting Test: Marc Tillotson T.C.C. # 5252035-U1 Credentials: 0 CSLB Licensed Contractor 0 SWRCB Licensed Tank Tester License Type: A, B, Ham, CIO License Number: 312844 Manufacturer Manufacturer Trainine Component(s)Date Trainin Expires Available upon request Q p ❑ ❑ Secondary Pipe - 3. SUMMARY OF TEST RESULTS Component: Pass Pail Not Tested Repairs Notes: Made Tank Annular - ❑ Q ❑ p Q p ❑ ❑ Secondary Pipe - ❑ ❑ ❑ ❑ D ❑ Turbine Sump - C 0 ❑ ❑ UDC ❑ p Fill Sump - _ ❑ �pM ❑ ❑ C CJ 0 D _ TLM Sump - p ❑ ❑ ❑ ❑ ❑ C C Spill Bucket - D ❑ p p a a ❑ o If hydrostatic testing was performed, describe what was done with the water after completion of tests: CERTIFICATION OF TECI•INICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING Ta the best of my knowledge, the facts slated in this document are accurate and in full compliance with legal requirements Technician's Signature: ry `�'`'�--tea ._.�..._._ Date: