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Secondary Containment Testing Report Form <br />This form is intended for use by contractors performing periodic testing of USTsecondary 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 far submittal to the local regulatory agency. <br />r FACIT.TTV INFORMATMN <br />Facility Name: Safeway # 2600 Date of Testing: 3/25/10 <br />Facility Address: 1987 W 11`" Street — Tracy CA 95376 <br />Facility Contact: I Phone: <br />Date Local Agency Was Notified of Testing : SB989 — <br />Name of Local Agency Inspector (if present during testing): <br />t 'rT. CT,N!_ f'fANJTQ A t TnQ TN WIQM ATMN <br />Company Name: ABLE Maintenance, Inc. <br />Technician Conducting Test: Kelley Burningham ICC# 5250610-U1 <br />Credentials: ® CSLB Licensed Contractor <br />SWRCB Licensed Tank Tester <br />License Type: A, B, Haz., C10 <br />License Number: 312844 <br />Manufacturer <br />Manufacturer Training <br />Component(s) Date Training Expires <br />Available upon request <br />7. SUMMARY OF TEST RESULTS <br />pairs <br />Component: Pass Fail Not Repairs <br />Component: <br />Tested Made Tested Made <br />Diesel Fill Sump MW Conversion <br />MOMIM <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: 3/25/10 <br />