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SEP -10-2009 14:24 Service Station Systems 408 938 8886 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 tasted. The completedform, written test procedures, and <br />printoutsfrom tests (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: Safeway #2707 1 Date of Testing_ 8/10/09 <br />Facility Address: 6425 N. Pacific Ave — Stockton CA 95207 <br />Facility Contact: I Phone: <br />Date Local Agency Was Notified of Testing : SB989 — <br />Name of Local Agency Inspector (if present during testing): <br />TESTING CONTRACTOR INFORMATION <br />Company Name: ABLE Maintenance, Inc. <br />Technician Conducting Test: Marc Tillotson ICC# 5252035 -UT <br />Credentials: ® CSLB Licensed Contractor SWRCB Licensed TankTestcr <br />License Type: A, B, Ha&, CLO License Number: 312844 <br />Manufaeturer Training <br />Manufacturer Component(s) Date,rraining Expires <br />Available upon request <br />SUMMARY F TEST RESULTS <br />Component, Pass Fail Not Repairs <br />Tested Made <br />component: Pass Fad Not Repairs <br />Tested Made <br />' IBM'' <br />-- <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <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 Sifnature: Date: 8/10/09 <br />