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JAN-31-2011 14:39 Service Station Systems 408 938 8888 P.02 <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 fotm to report results for all components tested The compleled,(orm, written test procedures, and <br /> printouts from tests (if applicable), should be provided to the facility owner/operatorfar submittal to the local regulatory agency. <br /> I. FACILITY INFORMATION <br /> Facility Name: Safeway#2707 Dme of Testing: 1/4/11 <br /> Facility Address; 6425 N Pacific Ave—Stockton CA 95207 <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing; SB999—6 month follow up <br /> Name of Local Agency Inspector(ftresent during resting): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name:ABLE Maintenance,Ina <br /> Technician Conducting Test: James Moore/I.C.C.05254517-UT <br /> Credentials: 0 CSLB Licensed Contractor F1,S WRCB Licensed Tank Tcstcr <br /> License Type:A,B,Haz.,CIO License Number: 312844 <br /> Manufacturer Trainin <br /> Manufacturer component(s)) Date Training Expires <br /> Available upon request <br /> 3. SUMMARY OF TEST RESULTS <br /> Component: Pass Fail Not Repairs Component: Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> 87 Fill Sump O ❑ ❑ 0 ❑ Cl ❑ ❑ <br /> 91 Fill Sump 0 ❑ ❑ ❑ ❑ ❑ Q ❑ <br /> Diesel Fill Sump ❑X ❑ ❑ ❑ ❑ Q ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ Q ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ a ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ 0 ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ Q ❑ ❑ ❑ ❑ <br /> No <br /> 0 Cl El ❑ <br /> ❑ 11 El 11❑ ❑ ❑ <br /> ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> Pump test truck used for testing <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best ofmy knowledge,the facts stated in this document are aecurate and in full compliance with legal requirements <br /> Technician's Signature: Date: 1/4/11 <br />