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JRN731-2011 14:39 Service Station Systems 408 938 eeee P.03 <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 completedform,written test procedures, and <br /> printouts from tests(fopplicable),should be provided to rhe facility owner/operator for submittal to the local regulatory agenc9,. <br /> 1. FACILITY INFORMATION <br /> Facility I Date of Testing:/ H/if <br /> Facility Address: Lr+lss5 <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing: SB989 wee 4 p<o, F6 LLpW U p <br /> Name of Local Agency Inspector(if present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: ABLE Maintenance,Inc. <br /> Technician Conducting Test: ,lames Moore/I.C.C.N9254517-UT <br /> C.cao.niala. ® C31,15 1,1 i, cu Gmiu actur U bwKI,1b Licensed IanK'fester <br /> License Type:A,B,HaL,C10 License Number: 312844 <br /> Manufacturer Trainln¢ <br /> Manufacturer Com ens Date Training E ires <br /> Available upon request <br /> 3, SUMMARY OF TEST RESULTS <br /> Component: pass Fait Not Repairs Notes: <br /> Made <br /> Tank Annular - ❑ ❑ ❑ ❑ <br /> Secondary Pipe - ❑ ❑ ❑ ❑ <br /> Turbine Sump - ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> UDC - ❑ p ❑ ❑ <br /> Fill Sump - -'-7 ❑ ❑ ❑ <br /> TLM Sump - ❑ ❑ ❑ ❑ <br /> ❑ ❑ 1 ❑ ❑ <br /> Spill Bucket • ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <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 acts stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature:_ i Dater' <br /> ! 1 <br />