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JUL-27-2011 15:32 Ser ice Station Systems 408 938 8888 P.02 <br /> Secondary Containment Testing Report Form <br /> This form is intended fr use by contractors performing periodic tasting of UST secondaty containment systems. Use the <br /> appropriate pages of this form to report results for all components tested The completedform,written test procedures, and <br /> printours from tests(if applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 11 FACILITY INFORMATION <br /> FacilityName: t lkisn J-Date of Testin ��7 <br /> Facility AddressCl^ mm <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified ofTcsting: S0989- QtbXk0 <br /> Name of Local Agency Inspector(ifpresent duringtevin,): <br /> 2. _ TESTING CONTRACTOR INFORMATXON <br /> Company Name:ABLE Maintenance,Inc. _ <br /> Technician Conducting Test: �«U � i hG �L.� �6® (®-�Credentials; 13 CSLB Licensrd tontractor J 0 SWRCB Licensed Tanis Tester <br /> License Type:A,B,Haz.,C10 License Number:11 3112844 <br /> Manufacturer Training <br /> Manufacturer _ _ � COMR2 snt(s) __ Date Training Ex fres <br /> Available upon request <br /> 3. SUMMARY OF TEST RESULTS <br /> Component: Pass Fail Not Repairs <br /> Tested Made Notes; <br /> Tank,Annular - ❑ ❑ ❑ ❑ <br /> Secondary Pipe - ❑ 0 <br /> ❑ 0 0 ❑ <br /> Turbine Sump - ❑ ❑ ��, -1 <br /> ❑ 0 ❑ 0 <br /> UDC - ❑ ❑ 0 a <br /> Fill Sump - 0 0 0 ❑ <br /> 0 ® ❑ <br /> TLM Sump ❑ 0 ❑ ❑ <br /> ❑ ❑ 0 ❑ <br /> Spill Bucket - 0 ❑ 0 U <br /> 0 ❑ ❑ 0 <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> CERTIFICATION OF TECHNICTAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To rise best of my knowledge,the fasts stated in this document are accurate and Infill compliance with legal requirements <br /> Technician's Signature: A..__ Date: (p/1Z%61 <br />