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NOV-11-2011 15:20 Service Station Systems 408 930 8285 P.02 <br /> Secondary Containment Testing Report Form <br /> This farm is intended for use by contractors performing periodic testing of UST secondary containment aystems. Use the <br /> appropriate pages of this farm to report results far all components tested, The completed form, written test procedures, and <br /> printouts from tests(if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: t_ �?i Date of Testing: Q //A i 1 <br /> Facility Address: • 4't <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing: SI3989 <br /> Name of Local Agency Inspector(if present during testing): <br /> 2. TESTLNG CONTRACTOR INFORMATION <br /> Company Name:ABLE Maintenance, Inc. <br /> Technician Conducting Test: ,lames Moore/I.C.C.#15254517-UT <br /> Credentials: ® CSLB Licensed Contractor 0 S WRCB Licensed Tank Tester <br /> License Type; A,B,Haz., C10 License Number: 312844 <br /> M_ _A»_gfactgrer Training <br /> Manufacturer Component(s) pate Training Expires j <br /> Available upon request <br /> 3. SUMMARY OF TEST RESULTS <br /> Component: Pass Fall Not Repairs Notes: <br /> Tested Made <br /> Tank Annular - ❑ E ❑ ❑ <br /> a ❑ ❑ ❑ <br /> Secondary Pipe - ❑ ❑ ❑ ❑ <br /> Q ❑ ❑ ❑ <br /> Turbine Sump - ❑ o 7 <br /> ❑ ❑ ❑ ❑' <br /> UDC - 0 C ❑ C <br /> Fill Sump - p C ❑ <br /> TIN Sump - ❑ ❑ ❑ ❑ <br /> ❑ D G ❑ � <br /> Spill Bucket - ❑ �? ❑ <br /> ❑ ❑ I Ll <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> CERTIMCATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To 11r a best of my knowledge,the facts stated In this document are accurate and ht full compliance with legal requirements <br /> Technician's Signature: Date: t// _ <br />