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Secondary Containment Testing Report Form This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the appropriate pages of this form to report results for all components tested The completed form, written test procedures, and printouts from tests (f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. FACILITY INFORMATION Facility Name: Safeway # 2600 Date of Testing: 3/29, 3/30, 3/31, 4/1 and 4/7/10 Facility Address: 1987 W 11'h Street — Tracy CA 95376 Facility Contact: Phone: Date Local Agency Was Notified of Testing: SB989 — Name of Local Agency Inspector (if present during testing): 10. TESTING CONTRACTOR INFORMATION Company Name: ABLE Maintenance, Inc. Technician Conducting Test: Mike Trejo ICC #5252033 -UT Credentials: ® CSLB Licensed Contractor 0 SWRCB Licensed Tank Tester License Type: A, B, Haz., C10 License Number: 312844 Manufacturer Trainin¢ Manufacturer Component(s) Date Training Expires Available upon request 11. SUMMARY OF TEST RESULTS Component: Pass Fail Not Tested Repairs Component: Made Pass Fail Not Tested Repairs Made 91fDiesel Tank Annular ® ❑ ❑ 0 ❑ ❑ ❑ ❑ 87-N Secondary Product ® ❑ ❑ ❑ 0 0 ❑ ❑ 91-N Secondary Product ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ Diesel- N Secondary Product © ❑ 0 ❑ ❑ ❑ ❑ ❑ 87-S Secondary Product ® ❑ ❑ 0 ❑ ❑ ❑ ❑ 91- S Secondary Product ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ Diesel -S Secondary Product ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ 0 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ I ❑ ❑ 0 If hydrostatic testing was performed, describe what was done with the water after completion of tests: CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING To the best of my knowledge, the facts stated in this document are accurate and in full compliance with legal requirements Technician's Signature: Date: 3/29, 3/30, 3/31, 4/1 and 4/7/10