Laserfiche WebLink
FEB -25-2011 15:47 Service Station Systems 408 938 8888 P.03 <br />Secondary Containment Testing Report Form <br />Tlaic form is intendedfor use by contractors performing periodic testing of USTsecondaty 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 (rf applicable), should be provided to the facility owner/operator far• submittal to the local regulatory agency. <br />1. <br />FACILITY INFORMATION <br />Facility Natne: Date of Testing: / /43 11 <br />Facility Address:; �;. c�a�•tt�. ��c-r��= jc=a 2}�� <br />Facility Contact: Phone: <br />Date Local Agency Was Notified of Testing . SB989 — 3 yr. Compliance <br />Mamie of Local Agency Inspector (if present during testing): <br />2, TESTING CONTRACTOR INFORMATION <br />Company Name; ABLE Maintenance, Inc. <br />PASS <br />Technician Conducting Test: James Moore / I.C.C. 45254519 -UT <br />Credentials: 0 CSLB Licensed Contractor <br />C1 SWRCB Licensed Tank Tester <br />License Type: A, B, Har, CIO <br />License Number: 312844 <br />Manufacturer <br />Manufaeturer Training <br />Component(s)) Date Training Expires <br />Available upon request <br />❑ <br />❑ <br />❑ <br />❑ <br />Component; <br />PASS <br />. Fail <br />Not <br />Tested <br />Repairs <br />Made <br />Notes, <br />Tank Annular - 'h <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Secondary Pipe - <br />❑ <br />❑ <br />G <br />Al L,Ne� <br />❑ <br />❑ <br />a <br />0 <br />Turbine Sump - fi <br />❑ <br />0 <br />❑ <br />– e—C <br />i� <br />❑ <br />U <br />0 <br />t1DC - 4- <br />❑ <br />❑ <br />❑ <br />Fill Sump - a <br />f <br />❑�� <br />0 <br />ZQ&N <br />n❑ <br />TGIF Sump <br />❑ <br />❑ <br />❑ <br />❑ <br />..��a <br />0 <br />❑ <br />0 <br />D <br />Spill Bucket - 1z <br />❑ <br />p <br />D <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 int full compliance with legal requirements <br />Technician's Signature. _ Date: `�/ <br />