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MAY707-2009 11:02 Service Station Systems <br />408 938 8888 P.03 <br />Secondary Containment Testing Report Form <br />This form is intended,fbr tese by contractors perfbrnring periodic testing of UST secondary containment systems. Use the <br />appropriate pages of this form to report results for all components tested. The cornpleled form, written test procedures. and <br />printouts from tests (if applicable.), should be provided to rhe facility owner/operator for submittal to the local regulatory agency. <br />FACT1,1TY INFORMATION <br />Facility Name: Sareway # 2600 Date of Testing: 4/24/09 <br />Facility Address: 1819 W. 11th Street —Tracy CA 95376 <br />Facility Contact: Phone: <br />Date Local Agency Was Notified of Testing : SB989 — Repair/Retest <br />Name of Local Agency Inspector (if present during le.iting): <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: ABLE Maintenance, Inc. <br />'technician Conducting Test: Marc Tillotson ICC# 5252035 -UT <br />Credentials: ® CSLB Licensed Conrractor SWRCB Licensed Tank Tester <br />License Type: A, B, Haz., C10 License Number. 312844 <br />WR <br />Manufacturer Trainirl; <br />Manufacturer Com oncnt(s) Date Training Expires <br />Available upon request <br />3. SUNIMARY OF TEST RESULTS <br />Component: Pass Fail Not Repairs <br />Tested Made <br />Component: pass Fail Not Repairs <br />Tested Made <br />91 B Secondary Product <br />87 Turbine Sump <br />®] <br />91. Turbine Sump <br />C7 <br />CI <br />UDC 3/4 <br />87 Fill Sump <br />89 Fill Sump <br />10 <br />C� <br />� <br />I <br />I <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />Used pump test truck <br />CERTIFICATION OF TECIMCIAN 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: <br />