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RUL-06-2010 14:18 Service Station Systems 408 938 sees P.03 <br /> Secondary Containment Testing Report Form <br /> This form is intended for use by contractors performing periodic resting of UST secondary containment systems. Use the <br /> appropriate pages ofthis form to report results jor all components tested. The completed form, written test procedures, and <br /> printouts from tests(if applicable), should be provided to the facility owner/operator far submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name; IZ-7o,7 I Date ofTesting: 7 /01 / to <br /> Facility Address: A tj , G OAC 43nC4-0(,J QA ct,5-2,a7 <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing: SB989- <br /> Name of Local Agency Inspector(ifprasent during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Campo Name:ABLE Maintenance,Inc. <br /> Technician Conducting Test LG g(5 = Gri a` 0 -() <br /> Credentials, ® CSLB Licensed Contractor 0 SWRCB Licensed'rank Tester <br /> License Type:A,B,Hae„CIO License Number: 312844 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training BHpires <br /> Available upon request v <br /> 3. SUMMARY OF TEST RESULTS <br /> Component; Pass Fail Not Repairs Notes: <br /> Tested Made <br /> Tank Annular - ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> Secondary Pipe - ❑ ❑ ❑ ❑ <br /> Turbine Sump - ❑ ❑ ❑ ❑ <br /> UDC - U ❑ ❑ p <br /> Fill Sump - p ❑ 09 1 JtN-3-WLAW iJl Al GOG 11J 8 q I <br /> TLM Sump - ❑ ❑ ❑ ❑ <br /> Spill Bucket - ❑ p ❑ ❑ <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 f(actctsssstaateddIIn this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: / y Date: 2 .1 t•W <br />