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MAY-16-2008 18:11 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 test procedures, and <br /> printouts front tests(if applicable), should be provided to the facility owner/operator for submitral to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name' Safeway#2707 1 Daze of Testing: 4/17/08 <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—Repair/Retest <br /> Name of local Agency Inspector(lf present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name:ABLE Maintenance,Inc. <br /> Technician Conducting Test: Marc Tillotson ICC#5252035-U1 <br /> Credentials: ® CSLB Licensed Contractor SWRCB Licensed Tank Tester <br /> License Type:A,B,Haz,C10 License Number: 312844 <br /> Manufacturer Training <br /> Manufacturer Component(s) DateTrainin Ex fires <br /> Available upon request <br /> 3. SUMMARY OF TEST RESULTS <br /> Component; Pass Fail Not Repairs Co Not Repairs <br /> Tested Made mpouent: Pass Fail Tested Made <br /> 87 Turbine Sump <br /> 91 Turbine Sump ® GS7 <br /> DSL Turbine Sump ff] <br /> 91 Fill Bucket X <br /> 87 Vapor Bucket X El <br /> If hydrostatic testing was perforined,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 />