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JAN -20-2009 09:33 Service Station Systems <br />408 938 8888 P.03 <br />Secondary Containment Testing Report Form <br />This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use tate <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 />t T A !'TT TTV MM'"IDTIA A'rinXT <br />Facility Name: Safeway # 2600 Date of Testing: 12/30/08 <br />Facility Address: 1804 W. 11`x' Street — Tracy CA 95376 <br />Facility Contact: I Phone: <br />Date local Agency Was Notified of Testing: SB989 — 3yr. Compliance Test <br />Name of Local Agency Inspector (if present during resting): <br />rrQ-rtVt_ CnNTRAVTnR TWORVIATION <br />Company Namc: ABLE Maintenance, Inc. <br />Technician Conducting Test: James Moore / I.C.C. #5254517 -UT Elodio Sanchez ICC# 5313877 -UT <br />Credentials: ® CSLB Licensed Contractor SWRCB Licensed Tank "fester <br />License Typc: A, B, Haz., C10 License Number: 312844 <br />Manufacturer Trainin <br />Manufacturer Com onent(s) Date Training Expires <br />Available upon request <br />z CTil1TIVIARV OF TEST RESC1i,TS <br />Not Repairs <br />Component: Pass Fail Tested Made <br />Component: Pass Fail Not Repairs <br />Tested Made <br />87 Tank Annular <br />® <br />LTDC 7/8 <br />89/91 Tank Annular <br />® <br />UDC 9/10 <br />191 <br />87 A Secondary Product <br />© <br />UDC 11/12 <br />0 <br />87 B Secondary Product <br />Q <br />UDC 13/14 <br />L <br />89 A Secondary Product <br />Q <br />UDC 15/16 <br />89 B Secondary Product <br />© <br />UDC 17/18 <br />91 A Secondary Product <br />Cisl <br />UDC 19/20 <br />91 B Secondary Product <br />® <br />87 Fill Sump <br />Lel <br />87 Turbine Sump <br />CI"sl <br />89 Fill Sump <br />® <br />k <br />89 Turbine Sump <br />El <br />91 Fill Sump <br />�l <br />91 Turbine Sump <br />UDC 1/2 <br />UDC 3/4 <br />Q <br />UDC 5/6 <br />i <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />Four drums left onsite. <br />CERTIFICATION Or 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 />Tech ir�Omani P' __ __ Date: <br />