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FEB-20-2008 09:03 Service Station Systems 408 938 Be% P.02 <br /> Secondary Containment Testing Report Form <br /> This lorm is talendeeiJur use hi:contractors perloraringp&iodk tcating of US%'secondur3: Use the <br /> uppropriale pagers of this form to report results jor all comp,unents tested The cdmpletud.Jorrn, wrillen test procedures, ufrd <br /> p intozols froon lesix(il applicahlel,shuvld be p),orided to the,acrlfty owner/operafor Jur Subi nitlal.to the to Cal regulafoly agent-V <br /> _ 1. FACILITY INFORMATION <br /> I Fad Iity Name: rksR 0 Date_of Testing: <br /> Facility Address: -2A '�t•, -,Q^ L -V <br /> 1 <br /> I Facility Contact: __ Phone: k <br /> l Date Local Agency Was Notified of Testing: SLi989 <br /> Name of Local Agency Inspector 01preseni daring tesling): I <br /> Z, TESTING CONTRACTOR INFORMATION <br /> Company dame: ABLE Maintenance, Inc. — <br /> Technician Conducting,Test: Mare Tillotson I.C.C,#5252035-U1 <br /> Credentials: ® CSLB Licensed Contractor J SWRCA Licensed Tank Tester <br /> Li—cc ttsr Type: A, 8,Fiaz.CIU License Number: 312$44 <br /> Manufacturer Trsinine <br /> Manufacturer component(s)) Date-t-rainin g Lx ices <br /> 'Available upon request <br /> SUMMARY OF TEST RESULTS <br /> -W <br /> Component; Not Repairs" �.w. I Pass Fail Notes: { <br /> _ Tested Made t t <br /> Tank Annular _--�— 7 S <br /> .Secondary Pipe <br /> Turbine Suiup Li <br /> UDC - jA..-- <br /> 4 <br /> c Fill Sump - '3 .� �c� .�a�.(� fi Iv <br /> If hydrostatic testing was performed, describe what was done with the water after completion of tests' <br /> x"Sl <br /> CERTIFICATION OF TVCHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To NjF best of my knowledge,the facts stetted in this document tire accurate and iut full cantpliance with legal requirements <br /> !'echnicittn's Daie:_�, �,_. ^__ <br />