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JAN -30-2013 10:48 Service Station Systems <br />40r2 933 8886 P.02 <br />Secondary Containment Testing Report )norm <br />This form 4 intended for use by contractors performing periodic testing of UST secondary containment systems. Use the <br />appropriate pages of thls form to report results for all components tested The completed form, written test procedures and <br />printouts from tests (if applicable), should be provided to the foediry owner/operator for submittal to the local regulatory agency. <br />1. <br />FI -TO -1 1F tsar aa.i <br />Facility Name: Data of Test' • 1 f--/13 <br />Facility Address: Ci' 'Z5� -tJ , A, E <br />Facility Contact: <br />Date Local Agency Was Notified of Testing: t SB999 — 3 yr. Compliance <br />Name of Local Agency Inspector (tfpresent during testing): <br />2. 'TESTING CONTRACTOR INFORMATInN <br />Company Name: ABLE Maintenance, Inc. <br />Pau <br />Technician Conducting Test: James Moore / I.C.C. 45254517•UT <br />Credentials: 0 CSLB Licensed Contractor <br />❑ SWRCB Licensed Tank Tester <br />License Type: A. a, Hoz, CIO I License Number: 312844 <br />..nw^�^.-�.Tr-..M.i.n-.� «�..n�.�..w .....r ✓w4.rn..:.a_.'.�w � t-....�. .. �.�y �.�.n...a �--.��.�..�. <br />nfaat_urer Training <br />Manufacturer Component(s) Date TrakWA F:x ires <br />Available upon regmest <br />❑ <br />❑ <br />❑ <br />Q <br />3. <br />SUMMARY OF TRP%T RF.CITI.TC <br />Component: <br />Pau <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />_ — Notes: <br />Tank <br />Tank Annular - <br />❑ <br />❑ <br />❑ <br />Q <br />❑ <br />❑ <br />❑ <br />Secondary Pipe - '"j <br />❑ <br />❑ <br />0 <br />❑ 1 <br />❑ <br />❑ <br />❑ <br />Turbine Sump - <br />V1 <br />p <br />I ❑ <br />❑ <br />UJ <br />❑ <br />1 ❑ <br />❑ <br />UDC - 23 <br />9,1 <br />❑ <br />1 ❑ <br />❑ <br />❑ . <br />❑ 1 <br />❑ <br />❑ <br />Fill Sump - <br />Tr I <br />❑ <br />❑ <br />❑ <br />\ICA-" gwt.--? - t <br />❑ <br />Rr 1 <br />❑ <br />❑ <br />1 k),ZX3 j?� 1 s <br />TLM Sump <br />❑ <br />❑ 1 <br />❑ <br />❑ <br />hYa Z-!X!o ,� p ? <br />❑ <br />Gt 1 <br />❑ <br />❑ <br />Spill Bucket c5r" <br />p <br />❑ <br />❑ <br />a <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 best of my Anowledge, theacts stated fn this dociumat are accurate and in full camptlance with legal requirements <br />Technician's Signaturg Date;' rw �j <br />