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REGEIVEL JAN 112016 ENVIRRM-I T41_ FACILITV INFORMATION Facility Name: Safeway 02707 Date of Tcstinc: 12[8/15 Facility Address: 6425 N. Pacific Avenue—Stockton CA 95207 D 1 Facility Contact: Phone: (209) 4724600 Date Local Agency Was Notified of Testing: 12/805 SB989— 3yr. Compliance Test Name of Local Agency Inspector (if presenr during rowing): ❑ ❑ Ar TnR FNPnRMATrf1N Company Name: ABLE Maintenance, Inc. Technician Conducting Test: James Moore I I.C.C. 05254517-tIT Credentials: ® CSLB Licensed Contractor SWRCH Licensed lank Tesicr License Type: A, B, Haz., CIO License Numher: 312844 Manufacturer Trainine Manulacturer Com onentlsl Date Iraining Expire, Available upon request Ci1MMARV OF TEST RESULTS Not Repairs Component: Pass Fail Tested Made Not Repairs Component: Pass Foil Tested Made 87 Tank Annular D 1 ❑ ❑ ❑ UDC 5/6 ® ❑ ❑ ❑ 91/Diesel Tank Annular ®r ❑ ❑ UDC 7/8 ® ❑ ❑ ❑ 87 Secondary Product ® ❑ ❑ UDC 9/10 ® ❑ ❑ ❑ 91 Secondary Product © ❑ ❑ UDC 11/12 ® ❑ ❑ ❑ Diesel Secondary Product ® ❑ ❑ UDC 13/14 ® ❑ ❑ ❑ 87 Vent ❑O ❑ ❑ UDC 15/16 © ❑ ❑ ❑91 Vent © ❑ ❑ 87 Fill Sump ® ❑ ❑ ❑ Diesel Vent D ❑ 0 ❑ 91 Fill Sump © ❑ 0 ❑ Vapor ® ❑ ❑ 0 Diesel Fill Sump ® ❑ ❑ ❑ 87 Turbine Sump ❑O ❑ ❑ ❑ Vent Sump ® ❑ ❑ ❑ 91 Turbine Sump ® ❑ ❑ ❑ Diesel Turbine Sump © ❑ ❑ ❑ UDC 1/2 ® ❑ 1 ❑ D UDC 3/4 ® ❑ ❑ ❑ If hydrostatic testing was performed, describe what was done with the water after completion of tests: Used pump test truck