Laserfiche WebLink
APR-30-2008 10:08 Service Station Systems 408 938 8888 P.02 <br /> Secondary Containment Testing Report Form <br /> This form is intended for use by contractors performing periodic testing of U.ST secondary containment systems. Use tine <br /> appropriate pages ofthis form to report resultsjbr all components tesled, The completed form, written test procedures, and <br /> printouts from tests(if applicable), should he provided to the facility owner/opFrator for submittal to the local regulatory agency, <br /> I• FACILI`Z'Y INFORMATION <br /> Facility Name: e5oOl�3 Date of Testing: �} / 3 <br /> Facility Address: Z -IT 1 t11a1 �t . LOO i C# ��Z <br /> Facility Contact: Phone: _~ <br /> Dace Local Agency Was Notified of-Testing, SB989- �- <br /> Name of Local Agency Inspector(if present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: ABLE Maintenance,Inc. <br /> I'eehnieian Conducting Test: (y�l KE Td2C3a .e,�'i. ��52U33-U7� <br /> Credentials: 0 CSLB Licensed Contractor Ej SWRCB LicensedTank Tester <br /> -e --�� <br /> License Type: A,B,Haz., C10 . r 12$44 <br /> ,. License Numbe.: 3 _ <br /> Manufacturer Trainin <br /> Manufacturer Components) Date Training Expires <br /> Available upon request <br /> _ <br /> 3• SUMMARY OF TEST RESULTS <br /> Component: Pass Fail Not Repairs Notes: <br /> i Tested Made <br /> Tank Annular - ❑ ❑ ❑ II <br /> Secondary Pipe. - ❑ 7] Fj <br /> Turbine Sump - i_J J ❑ 0 �- <br /> UDC - El ❑ G C i <br /> Fill Sump <br /> TLM Sump - ❑ ❑ I �; <br /> ❑ ❑ F ❑ <br /> Spill Bucket - ❑ ❑ ❑ �� - _ __ <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 hest of my knowledge,the facts crated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: L J �.- _ _^_ Dater <br />