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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: 09/20/17 Facility Address: 1987 W. 11th St., Tracy CA 95376 Facility Contact: Manager Phone (209) 830-2950 ❑ Initial ❑ Repair Test Date Local Agency Was Notified of Testing: 08/29/17 ❑ 6 Month ❑Other Name of Local Agency Inspector (if present during testing): No Inspector on Site p Triennial Fail 2. TESTING CONTRACTOR INFORMATION Company Name: Able Maintenance Inc Technician Conducting Test: Erik Salinger/ I.C.0 #8729425 Credentials: [Z CSLB Licensed Contractor ❑ SWRCB Licensed Tank Tester I p ICC UST Service Technician License Type: I License Number: 312844 Manufacturer Training Manufacturer Component(s) Date Training Expires Available Upon Request 3. SUMMARY OF TEST RESULTS Component Pass Fail Not Tested Repairs Made Component Pass Fail Not Tested Repairs Made 87 Tank Annular 121 El ElUDC 3/4 ❑ ❑✓ El❑ 91/ Diesel Tank Annular © El ElUDC 5/6 ❑ © El ❑ 87 Secondary Product ❑ ❑ ❑ El UDC 7/8 El 2 El❑ 91 Secondary Product ❑ ❑ ❑ 1 ❑ UDC 9/10 ❑ ❑✓ ❑ ❑ Diesel Secondary Product ❑ ® ❑ ❑ UDC 11/12 ❑ © ❑ ❑ 87 Turbine Sump © ❑ ❑ El UDC 13/14 ❑ © ❑ ❑ 91 Turbine Sump © ❑ ❑ ❑ UDC 15/16 ❑ ❑✓ ❑ ❑ Diesel Turbine Sump © 0 ❑ m UDC 17/18 ❑ ❑✓ ❑ ❑ 87 Fill Sump [3 ❑ ❑ ❑ UDC 19/20 ❑ ❑✓ ❑ ❑ 91 Fill Sump © ❑ ❑ ❑ TLM Sumps Not Equipped ❑ ❑ © ❑ Diesel Fill Sump © ❑ ❑ ❑ Spill Buckets Not Required ❑ ❑ ❑� ❑ UDC 1/2 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ If hydrostatic testing was performed, describe what was done with the water after completion of tests: Used Pump Test Truck For anv eouinment canable of generating a print out of test results. you must attach a copv of the test report to this certification v ❑ System printout attached. 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: 09/20/17