Laserfiche WebLink
FEB-25-2011 15:25 Service Station Systems 408 938 8888 P.03 <br /> t <br /> Secondary Containment Testing Report Form <br /> .This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the <br /> appropriate pages of thisform to report results for all components tested, The completed form,written test procedures, and <br /> printouts front tests(if applicable),should be provided to the facitiry owner/operator for submittal to the local regulatory agency. <br /> I. FACILITY INFORMATION <br /> Facility Name: ,lc�G�- la'0lo%�F TDate of Testing: / 444 I! <br /> Facility Address: ` l 4-c-' <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing, SU989-3 yr.Compliance <br /> Name of Local Agency Inspector(if present during testing): <br /> Z. TESTING CONTRACTOR INFORMATION <br /> Company Name:ABLE Maintenance,.lne. <br /> Technician Conducting Test: James Moore/I.C.C.#5254519-UT <br /> Credentials: 0 CSLB Licensed Contractor 0 SWRCB Licensed Tank Tester <br /> License Type:A,B,Haz„CIO w License Number: 312844 <br /> Manufacturer Trsiining <br /> Manufacturer Comtmnent(s) nate Training Expires <br /> Available upon regaest <br /> 3. SUMMARY OF TEST RESULTS <br /> Component: Pass Fail Not Repairs Notes: <br /> Tested Made <br /> Tang Annular - �� ❑ ❑ a <br /> ❑ 0 ED ❑ <br /> Secondary Pipe -2 1 ❑ ❑ <br /> Turbine Sump - Z ❑ ❑ ❑ <br /> D ❑ ❑ ❑ <br /> UDC - 4- ❑ ❑ ❑ <br /> Fill Sump__- 0 ❑ ❑ ❑ <br /> TLM Sump ❑ ❑ ❑ ❑ <br /> Spill bucket - ❑ ❑ ❑ <br /> D ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING TI:IIS TESTING <br /> To the best of nV knowledge,the f cts stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: _® Date: /' � <br />