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JUN,-20-2011 07:40 Service Station Systems 408 938 8888 P.02 <br /> Secondary Containment Testing Report Form <br /> 7%isfort»is intended for use by eomraators performing periodic testing of W secondwy containment systems. Use the <br /> appropriate pages of this form to report resulls for all components tested The completed form,written test procedures, and <br /> printouts from tests(f applicable),should be provided to the faciliittyownerloperator ffor submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> ATIOli <br /> Facility Name: lA-- I pate of Testing:0 M 10 <br /> Facility Address: 'Z:P22 -4� W- 4:=,00 <br /> Facility Contact: phone: <br /> Data local Agency Was Notified of Testing: SR999—3 yr.Compliance <br /> Naive of LoW Agency Inspector(f presen/during testing): <br /> TESTING CONTRACTOR INFORMATION <br /> CommNantes ABLE Maintenance,Inc. <br /> Technician Conducting Test: Jamas Moore/LCC.#5254517-UT <br /> Credentials: ® CSLB Licensed Contractor 17 SWRCR Licensed Tank Tester <br /> License Type:A,B,Ilan.,CIO License Number: 312844 <br /> n fa e T in' <br /> Manufamuer Conn s Date Training Ines <br /> Available upon request <br /> 3. SUMMARY OF TEST RESULTS <br /> Component: pass Fait Not Roadies Notes: <br /> Te:ua Made <br /> Tams Annular - 0 ❑ ❑ WZ <br /> 0 ❑ ❑ D <br /> Secondary Pipe 9" t: <br /> ❑ 0 L 0 ❑ 7-aq--j <br /> Turbine Sump • ❑ D D 9110 0:1,4, t t'�i sus <br /> ❑ 0 ❑ ❑ <br /> UDC - A ❑ D <br /> Q ❑ ❑ 0 <br /> Fill Sump - 0 0 0 <br /> ❑ Q ❑ Q <br /> TLM Sump - 0 ❑ V ❑ <br /> Spill Bucket - 0 d ❑ �QC7 <br /> 0 d 1 0 ❑ <br /> if hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> _IV c*- VS O-` —T'T=; *-14: <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,the facts sta let this doement are accurate and lit full compllance WO legal rquirements <br /> Technician's Signature: Date: PP ' <br />