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SWRCB,January 2002 Page of <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 test 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 /> Facility Name:Fast&Easy Mart Date of Testing:05/24/2018 <br /> Facility Address:10878 N.Highway 99,Stockton,CA 95212 <br /> Facility Contact:Mike Ali Phone:209-931-6154 <br /> Date Local Agency Was Notified of Testing:5/16/18 <br /> Name of Local Agency Inspector(if present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name:Confidence UST Services <br /> Technician Conducting Test:Frank Amesto <br /> Credentials: ?i CSLB Licensed Contractor SWRCB Licensed Tank Tester <br /> License Type:A. Haz,C61-D40 License Number:804904 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> C can use service technician 10/25/2019 <br /> INCON TS-STS 01/19/2020 <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Repairs Not Repairs <br /> Component Pass Fail Tested Made Component Pass Fail Tested Made <br /> 91n/91s/DSL annular z ❑ ❑ ❑ UDC 5/6 z ❑ ❑ ❑ <br /> 87 annular 0 ❑ ❑ ❑ UDC 7/8 z ❑ ❑ ❑ <br /> 87 secondary piping 0 ❑ ❑ 1 ❑ 87 vapor bucket z 1 ❑ ❑ ❑ <br /> 91 n secondary piping 0 ❑ ❑ ❑ 91 n vapor bucket ❑ z ❑ ❑ <br /> 91 s secondary piping z ❑ ❑ ❑ 91 s vapor bucket D ❑ ❑ ❑ <br /> diesel secondary piping z ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 87 STP z ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 91 n STP E ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 91 s STP 2 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> diesel STP Z ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> UDC 1/2 0 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> UDC 3/4 El 11 11 ❑ El El ❑ <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 Signature:_��,,� - - Date:05/24/2018 <br />