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JUN -04-2008 14:43 Service Station Systems <br />408 938 8888 P.02 <br />Secondary 1 , Report Form <br />This form is intended for use by contractors performing periodic testing of UST secondary containment systems. U.se the <br />appropriate pages of this form to report results for all components tested, The completedform, written test procedures, andprintouts from tests (if applicable), should be provllled to the facility ownerloperator for submittal to the local regulatory agency. <br />1( ',.\iR �� �= \))) FACILITY INFORMATION <br />Facility Name: �e-te.+ +� {'?ne►�,�_- Dete of Testing- /21 1 2.4�5& <br />FacilityAddress: 2a ..�•s..-+z�;,tt-sem .r �•�• c^c� <br />Facility Contact: Rhone: <br />Date Local Agency Was Notified of Testing: SB989 -- 3yr. Compliance Test <br />Name of Local Agency Inspector (Y'present during testing)- <br />2. <br />CONTRACTOR INFORMATION <br />Company Name: ABLE Maintenance, Inc. <br />Technician Conducting Test: James Moore / .I.C.C. ii5254517-UT <br />Credentials: ® CSLB Licensed Contractor <br />License Type: A, B, Haz., CIO <br />0 SWRCB Licensed Tank Tester <br />License Number: 312€344 <br />Manufacturer <br />......... . <br />Manufacturer 'Training <br />Components} Date Training Expires <br />Available upon request <br />91 <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 Ilse best of my knowledge, the facts stated in this document are accurate and u: full compliance with legal requirements <br />Technician's Signature:,��., _ _ Date:5-;z-1 <br />J <br />ax <br />W-119641 114 ti IVA W 101q�� <br />n' <br />RON - <br />M� <br />iTurbine Sump <br />� <br />GI <br />�� <br />p ✓ • G <br />TLM Sump J� <br />Mm <br />Spill •© <br />' ' CSI <br />�i <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 Ilse best of my knowledge, the facts stated in this document are accurate and u: full compliance with legal requirements <br />Technician's Signature:,��., _ _ Date:5-;z-1 <br />J <br />