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JUN -04-2008 14:50 Service Station Systems 408 938 8888 P.15/19 <br />0 <br />Secondary Containment Testing Report Form <br />This form is intended for use by contractors pelfonning periodic testing of UST secondary containment systems. Use the <br />appropriate pages of this form to report results,Jnr all components tested. The completed form, written test procedures, and <br />printouts from tests (lfapplicuble), shoat(d be provided to the facility ownerloperator for submittal to the local regulatory agency. <br />FACILITY 1NFnRMATION <br />Facility Name: 04..y Daie of Testing: <br />Facility Address: <br />Facility Contact: Phone: <br />Date Local Agency Was Notified of Testing : SB989 — 3yr. Compliance Test <br />Name of Local Agency Inspector (tf present during testing): <br />Company Name: ABLE Maintenance, Inc.- <br />Pass <br />Tedwician Conducting Test: James Moore / I.C.C. #5254517-11T <br />Credentials: 0 CSLB Licensed Contractor <br />0 SWRCB Licensed Tanis Tester <br />License Type: A, B, Ha z. CIO <br />License Number: 312844 <br />Manufacturer <br />Manufacturer Tralnin¢ <br />Co onent s Date Training Expires <br />Available upon request <br />❑ <br />Q <br />Component: <br />'nk <br />if <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />Notes: .a.. <br />7:` Annular <br />❑ <br />Secondary Pipe - <br />0 <br />0 <br />❑ <br />0 <br />Turbine S urap - Al- <br />0 <br />0 <br />fit, --i i -0�qv <br />z <br />Cl <br />0 <br />0 <br />❑ <br />A ROVW PQ%W Q 1 P t testa <br />UDC - <br />❑ <br />G <br />0 <br />❑ <br />d <br />❑ <br />0 <br />Fill Sump - <br />0 <br />❑ <br />❑ <br />❑ <br />❑ <br />n <br />0 <br />TLM Sump - <br />❑ <br />0 <br />0 <br />0 <br />rJ <br />❑ <br />❑ <br />❑ <br />i IGt;,T , WA Vii., (Aty*2 t11R. 7 M <br />Spill Bucket -1-- <br />0 <br />0 <br />W, f <br />--v*vvre— <br />❑ <br />❑ <br />❑ <br />❑ <br />-tgUAji P 54 4471a:- <br />a 1a: <br />if hydrostatic testing was performed, describe what was done with the water atter completion of tests: <br />CERTIFICATIO14 OP TECHNICIAN RESPONSIBLE FAR CONDUCTING THIS TESTING <br />To the best of my knowledge, the facts stated in this document are accurate and in fall compliance with legal requirements <br />t <br />1 <br />Technician's Signature: i � Date: 6-s I - G''s <br />