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DEC-05-2011 10:24 SERVICE STATION 14089388888 P.02 <br /> Secondary Containment Testing Report Form <br /> This form 0 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 tart procedures, and ? , <br /> prfntouts from tests(if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1, FACILITY WORMATION <br /> . Facility Name Y 7-7 Data of'resting: // //ty 11 <br /> Facility Address: f,�-ca4 W I R` .fr <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing: SB989-3 yr.Compliance <br /> Y <br /> Name of Local Agcney Inspector rifpremv during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: ABLE Maintenance,Inc. <br /> Technician Conducting Test: James Moore/I.C.C.#5254317-UT <br /> Credentials: ® CSLB Licensed Contractor J SWRCB Licensed Tank Tester : <br /> License Type:A,13,Ilaz., CIO License Number: 312844 <br /> ......�_ ar-...rte..-��..:""�' r:.���.+...,�_-....—rte - - -- " .-'�^... "".—�'�t"'""'."""_n,�wi..-•►� — •'� �2, , <br /> Mapl{fRgWer Trainft <br /> Manufgcnuer Com hent s Date Training Expires <br /> Available up2n request <br /> ak' <br /> 3, SUMMARY OF TEST RESULTS <br /> Component: Pass Fell Not Repilre Notems <br /> Tested I MAde <br /> Tank Annular - ❑ ❑ ❑ ' <br /> Secondwy Pipe - :s ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> Turbine Sump - ' 2 ❑ ❑ ❑ <br /> UDC 7 ❑ ❑ ❑ 3, <br /> Cl ❑ Cl 0 <br /> Fill Sump - -2'7 ❑ ❑ Q <br /> ❑ ❑ 11 0 <br /> TLM Sump - ❑ ❑ L7 ❑ ia< .0 <br /> A <br /> ,I <br /> ❑ ❑ C ❑ <br /> Spill Bucket - ❑ q ❑ b <br /> If hydrostatic testing was performed,describe wbat was done with the water after completion of tests: <br /> CERTIFICATIONOF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,eh acts stated In this doeunvenl are accurate and In full compliance with legal requirements <br /> Technician's Signature: Date: �{ ! 1 tom •�1 '% <br />