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JUN-16-2010 09:07 Service Station Systems 408 938 8888 P.02 <br /> Secondary Containment Testing Report Form <br /> chis 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 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: Date of Tening: /7 10 <br /> Facility Address: ' -2. e�J . "",mac.'—c °,�\.�n� :rev-Tc- ��.�-• <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing, SB989—3 yr.Compliance <br /> Name of Local Agency Inspector(fpresent during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name:ABLE Maintenance,Inc, <br /> Technician Conducting Test: James Moore/I.C.C.#5254517-UT Sam Sousa/I.C.C.#5254516-UT <br /> Credentials: Z CSLB Licensed Contractor 0 SWRCB Licensed Tank Tester <br /> License Type.A,B,Haz,,CID License Number. 312844 <br /> M__anal'aciuret'Txa.in_i�� <br /> ManufacmeT Com en s Date TrainingEx fres <br /> Available upon request <br /> 3. SUMMARY OF TEST RESULTS <br /> Component: Pass Fail Not Repairs (Votes; <br /> Tested made <br /> Tank Annular - ❑ © We'r ftNtIVLAOWe' <br /> 0 C ❑ 0 <br /> Secondary Pipe • ❑ ❑ ❑ <br /> Turbine Sump - ❑ ❑ ❑ <br /> CJ � ❑ <br /> UAC - e ❑ ❑ ❑ <br /> 0 ❑ ❑ ❑ <br /> Fill Sump 0 0 0 <br /> ❑ ❑ ❑ ❑ <br /> TLM Sump - 0 0 ❑ ❑ W 25s U �, <br /> Spill Bucket - p ❑ 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 facts stated In this document are accurate and In full compliance with legal requirements <br /> Technician's Signature: _ eW,„_ Date:_ t'O <br />