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AUG-29-2011 15 19 Service Station Systems 408 938 8888 P.02iO4 <br /> oecondary Containment Testing Report Form <br /> T his form is Intended for use by contractors performing periodic testing of UST secondary containment systems. Use the <br /> appropriate pages of this form to report results far all components tested. The completed form, written test procedures, and <br /> printouts from tests f fapplicaNe),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1, FACILITY WFORMATION <br /> Facility Name: &t p _'27 bate of Testing: -1 /Z11 <br /> FacilityAddress: y ) Z <br /> Facility Contact: Phone: zo 9 - 2ga q - <br /> Date Local Agency Was Notified of Testing,- SB989- <br /> Natne of Local Agency Inspector f f present during testing): t <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name:ABLE Maintenance,Inc. <br /> Technician Conducting Test: s CC, <br /> Credentials: 0 CSLB Licensed Contractol 0 SWRCH Licensed Tank Tester <br /> License Type:it,B,Haz.,CIO License Number; 312844 <br /> Manufacturer Tmining <br /> Manufacturer Com nent s Date Training Ex ices <br /> Available u on request <br /> 3. SUMMARY OF TEST RESULTS <br /> Component: Pass Fafl Not Repairs Notes; <br /> Tested Made <br /> Tank Annular - 0 ❑ 0 ❑ <br /> Secondary Pipe - p ❑ 1 ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> Turbine Sump u n <br /> 0 ❑ ❑ ❑ c.Ja l <br /> UDC - ❑ ❑ C ❑ <br /> C: .1 C ❑ <br /> Fill Sump - [I I ❑ ❑ ❑ <br /> ❑ D p ❑ <br /> TLM Sump - o ❑ ❑ ❑ <br /> Spill Bucket - ❑ ❑ ❑ ❑ <br /> ❑ 7 1 ❑ ❑ <br /> If hydrostatic testing was perfonred,describe what was done with the water after completion of tests: <br /> L_eS:1 Z- d.ex-< <o•2 4lfuw�5 C� �. �-1 -e- <br /> CERTIFICATION OF TRCHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,the facts stated in this document are accurate and In full compliance with legal requirements <br /> Technician's Signature: Date: -7/2A 1/ <br />