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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 this 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 facility owner/operator for submittal to the local regulatory agency. <br />L`Ad IT TTV ThrVnIDM ATTfAV <br />Facility Name: Safeway # 2600 Date of Testing: 3/19/10 <br />Facility Address: 1987 W I 11 Street — Tracy CA 95376 <br />Facility Contact: Phone: <br />Date Local Agency Was Notified of Testing: SB989 — <br />Name of Local Agency Inspector (if present during testing): <br />Trc.Tn�.n I�AAfTD A!`TAT) T1UL`l1D11,fATTl1N <br />Company Name: ABLE Maintenance, Inc. <br />Technician Conducting Test: Mike Trejo ICC #5252033 -UT <br />Credentials: ® CSLB Licensed Contractor SWRCB Licensed Tank Tester <br />License Type: A, B, Haz., C10 I License Number: 312844 <br />Manufacturer Training <br />Manufacturer Component(s) Date Training Expires <br />Available upon request <br />z cT TMM A R V OF TEST RESULTS <br />Not Repairs Component: Pass Fail Not Repairi <br />Component: Pass Fail Tested Made Tested Made <br />Before Diesel Conversion <br />91 Fill Sump <br />We <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 knowledge, the facts stated in this document are accurate and in full compliance with legal requirements <br />Technician's Signature: Date: 3/19/10 <br />