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JAN-31-2013 E9:32 Service Station Systems 408 938 888E P.82 <br /> Secondary Containment Testing Report Form <br /> 7hls form is Wended for use by contractors performing periodic testing of W secondary containment systems. Use the <br /> appropriate pages of this form to report results for all components tested rhe completed form, written test procedures, and <br /> printouts front tests(f applicahle),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACELITY INFORMATION <br /> Facility Name: i� is 4 -.1-PatoofTest1g. N /`Il l3 <br /> Facility Address: ¢sem MP - ^� Y 4, - 't + 4c, :0= <br /> Facility Contact; G,1 Vp e A- Phone: )o _ _)'�z _ 7Y�, <br /> Date Local Agency Was Notified of Testing: J7 SB989-3 yr.Compliance <br /> Name of Local Agency Inspector(ifpresent during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> VCredtentials: <br /> any Name,ABLE Maintenance,Inc. <br /> cian Conducting Test: James Moore/T.C.C.#5254517-UT <br /> 0 CSLB Licensed Contractor 0 SWRCB Licatued Tank Tester <br /> sa Type:A,B,Har♦,C10 License Number: 312844 <br /> .4,_r.:-r, "S" '!s :'.4'7z_"'✓^..is'b;a. ..*bz— <br /> Ma�nutaetarcr Treini� <br /> Manufacturer Com ongp s Date Training Expires <br /> Available upon request <br /> 3. SUMMARY OF TEST RESULTS <br /> Component: Pass nit Not Repairs Notes: <br /> Tested Made <br /> Tank Annular - 1 0 Q ❑ <br /> ❑ ❑ ❑ ❑ <br /> Secondary Pipe - 'Z- D r <br /> Turbine Sump - I ❑ r p <br /> ❑ ❑ ❑ ❑ <br /> UDC - -5 ❑ ❑ ❑ Q��p . �o*..�' ► � <br /> 0 D 0 <br /> Fill Sump - Z ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> TLM Sump - 4 ❑ ❑ ❑ ❑ <br /> 0 0 ❑ D <br /> Spill Bucket - •k ❑ 0 Q r'C CGL' <br /> Li ❑ ❑ ❑ <br /> if hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIStESTINC <br /> To the best of my knowledge,Ike f is sited In this dorument are accurate attd to fall eampliance Wlk legal requlrenumis <br /> i <br /> Technician's Signature: Date: ' '� <br />