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JUL-09-2009 15:32 Service Station Systems <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 text procedures, and <br />printouts from tests (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1, FACILITY INFORMATION <br />FacilityName: Safeway # 2707 1 Date of Testing: 11/7108 <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 />Company Name: ABLE Maintenance, Inc. <br />Technician Conducting Test: Marc Tillotson ICC# 5252035—U1 <br />Credentials: to CSLB Licensed Contractor SWRCB Licensed Tank Tester <br />License Type: A, B, Hat., CIO I License Number. 312844 <br />upon request <br />1 VITMMARV OF TEST RESITI: fS <br />Component: Pass Fail Not Repairs <br />Tested Made <br />Component: Pass Fail Not Repairs <br />Tested Made <br />• • •. ' .. <br />it to il._ <br />el <br />���__'. <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />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 <br />