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RECEIVED <br />Secondary Containment Testing Report Form OCT 2 U 2017 <br />ENVIRONM T EALTH <br />This form is intended for use by contractors performing periodic testing of UST secondary containment s T��rl� <br />appropriate pages of this form to report results for all components tested. The completed form, written tes procee <br />printouts from tests (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />FACILITY INFORMATION <br />Facility Name: Safeway #2600 Date of Testing: 09/20/17 <br />Facility Address: 1987 W. 11th St., Tracy CA 95376 <br />Facility Contact: Manager I Phone (209) 830-2950 ❑ Initial <br />❑ Repair Test <br />Date Local Agency Was Notified of Testing: 08/29/17 ❑ 6 Month <br />❑Other <br />Name of Local Agency Inspector (if present during testing): No Inspector on Site 0 Triennial <br />Fail <br />TESTING CONTRACTOR INFORMATION <br />Company Name: Able Maintenance Inc <br />Technician Conducting Test: Erik Salinger/ I.C.0 #8729425 <br />Credentials: 0 CSLB Licensed Contractor ❑ SWRCB Licensed Tank Tester 0 ICC UST Service Technician <br />License Type: License Number: 312844 <br />Manufacturer Training <br />Manufacturer Component(s) Date Training Expires <br />Available Upon Request <br />3. SUMMARY OF TEST RESULTS <br />Component <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />Component <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />87 Tank Annular <br />0 <br />❑ <br />❑ <br />❑ <br />UDC 3/4 <br />❑ <br />0 <br />❑ <br />❑ <br />91/ Diesel Tank Annular <br />© <br />❑ <br />❑ <br />❑ <br />UDC 5/6 <br />❑ <br />0 <br />❑ <br />❑ <br />87 Secondary Product <br />❑ <br />0 <br />❑ <br />❑ <br />UDC 7/8 <br />❑ <br />❑� <br />❑ <br />11 <br />91 Secondary Product <br />❑ <br />0 <br />❑ <br />❑ <br />UDC 9/10 <br />❑ <br />0 <br />❑ <br />❑ <br />Diesel Secondary Product <br />❑ <br />0 <br />❑ <br />❑ <br />UDC 11/12 <br />❑ <br />21 <br />❑ <br />❑ <br />87 Turbine Sump <br />0 <br />❑ <br />❑ <br />❑ <br />UDC 13/14 <br />❑ <br />0 <br />❑ <br />❑ <br />91 Turbine Sump <br />0 <br />❑ <br />❑ <br />❑ <br />JUDC 15/16 <br />❑ <br />0 <br />❑ <br />❑ <br />Diesel Turbine Sump <br />0 <br />❑ <br />❑ <br />0 <br />UDC 17/18 <br />❑ <br />0 <br />❑ <br />❑ <br />87 Fill Sump <br />0 <br />1 ❑ <br />❑ <br />❑ <br />UDC 19/20 <br />❑ <br />0 <br />❑ <br />❑ <br />91 Fill Sump <br />0 <br />❑ <br />❑ <br />❑ <br />TLM Sumps Not Equipped <br />❑ <br />❑ <br />© <br />❑ <br />Diesel Fill Sump <br />© <br />❑ <br />❑ <br />❑ <br />Spill Buckets Not Required <br />❑ <br />❑ <br />0 <br />❑ <br />UDC 1/2 <br />❑ <br />0 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />if hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />Used Pump Test Truck <br />For any equipment capable of generating a print out of test results, you must attach a copy <br />of the test report to this certification ❑ System printout attached. <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: 09/20/17 <br />