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SEP-25-2008 12:55 Service Station Systems 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 the <br /> appropriate pages of this form to report results for all components tested. The completed form,written rest procedures, and <br /> printouts from tests(if applicable), should be provided to the facility owner/operatorfor submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Safeway#2707 1 Date of Testing: 8128/08 <br /> Facility Address: 6425 N.Pacific Ave–Stockton CA 95207 <br /> Facility Contact: I Phone: (209)472-8600 <br /> Date Local Agency Was Notified of Testing: SB989– <br /> Name of Local Agency Inspector(if present during testing): <br /> Z. TESTING CONTRACTOR INFORMATION <br /> Company Name:ABLE Maintenance,Inc. <br /> Technician Conducting Tcst: Marc Tillotson ICC#5252035–U1 <br /> Credentials: ® CSLB Licensed Contractor SWRCB Licensed Tank Tester <br /> License Type:A,B,Haz.,CIO License Number: 312804 <br /> ,n <br /> Manufacturer Training <br /> factueCom nent(s) Date TrainingExpires <br /> AvailabMeuprer— <br /> 3. SUMMARY OF TEST RESULTS <br /> Component: Pass Fail Not Repairs Com Not Repairs <br /> Tested Made Component: Pass Fail Tested Made <br /> 87 Turbine Stump El <br /> UDC 7/8 191 <br /> 91 Fill Bucket <br /> 87 Vapor Bucket p <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 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: <br />