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RUG•-06-2010 14:18 Service Station Systems 408 938 8888 P.02 Secondary Containment Testing Report Form This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the appropriate pages of this form to report results,for all components tested. The completed form, written test procedures, and printouts from tests(f applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. I. FACILITY INFORMATION Facility Name: Safeway is 2707 1 Dale of Testing: 7/21/10 Facility Address: 6425 N Pacific Arc—Stockton CA 95207 Facility Contact: Phone: Date Local Agency Was Notified of Testing; SB989—Repair/Retest Name of Local Agency Inspector(ff present during testing): 2. TESTING CONTRACTOR INFORMATION Company Name:ABLE Maintenance,Inc, Technician Conducting Tcst: Mike Trejo ICC 05252033-U1 Credentials: E CSLB Licensed Contractor ❑S WRCB Licenced Tank Tester . I,icen,e'rvpe:A, B,Haz.,C10 License Numher: 312844 771 Manufacturer TrainineManufacturer Component(s) Available upon request 3. SUMMARY OF TEST RESULTS Component; Pass Fail Not Repairs Component: Pass Fail Nat Repairs F Tested Made Tested Made 87 Fill Sump ® ❑ ❑ ® ❑ 11 ❑ G 91 Fill Sump ® ❑ ❑ 1`il ❑ ❑ ❑ ❑ Diesel Fill Sump ® ❑ ❑ ® ❑ ❑ ❑ ❑ ❑ CO3 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ a ❑ ❑ ❑ ❑ © ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ 10000 11 ❑ ❑ ❑❑ ❑ ❑ ❑❑ ❑ ❑ ❑ ❑ ❑ ❑ If hydrostatic testing was performed,describe what was done with the water after completion of tests: CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING To the best of my knowledge,the facts stated in this document are accurate and in full compliance with legal requirements Technician's Signature: Date: 7/21/10