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RECEIVED <br /> SEP 1 1 2015 <br /> SWRCB,January 2002 <br /> Page of <br /> HE <br /> Secondary Containment Testing ALTH <br /> This form is intendedfor use by contractors performing periodic testing of UST secondary containment systems. Use t,':e <br /> appropriate pages of this form to report results for all components tested The completed form,written fest procedures,and <br /> printouts from tests(f applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> z z�'ty 1. FACMITY INFORMATION <br /> FacilityName: ARP Mini Mart 76 DateofTesting: June 23, 201 5 <br /> Facility Address: 25 75 So.Patterson,Tracy,CA.95376 <br /> Facility Contact: Phil Elder Phone: <br /> Date Local Agency Was Notified of Testing: p(p-d 7— <br /> Name of Local Agency Inspector(f present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Reliable Petroleum Services Inc. <br /> Technician Conducting Test: Ernesto B e r n a be <br /> Credentials: %)CSLB Licensed Contractor Q SWRCB Licensed Tank Tester <br /> License Type: A License Number: 8 8 3 7 0 6 <br /> Manufacturer Trainine <br /> Manufacturer Com onen s Date Training Expires <br /> INCON TS-STS august 06,2015 <br /> ICC Service Tech August 10,2015 <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fait Not Repairs <br /> Tested Made Tested Made <br /> Annular 87 Syphon H ❑ ❑ ❑ STP Sump 91 ® ❑ ❑ ❑ <br /> Annular 87 Master ® ❑ ❑ ❑ UDC 1 /2,• ® ❑ ❑ ❑ <br /> Annular 87 Slave g ❑ ❑ ❑ UDC 3/4 ® ❑ ❑ ❑ <br /> Annular 91 ® ❑ ❑ ❑ UDC 5/6 ® ❑ ❑ ❑ <br /> Secondary 87 Syphon g ❑ ❑ ❑ UDC 7/8 ® ❑ ❑ ❑ <br /> Secondary 87 Master g ❑ ❑ ❑ Fill Sump 87 Syphon 9 ❑ ❑ ❑ <br /> Secondary 87 Slave ® ❑ ❑ ❑ Fill Sump 87 Master N ❑ ❑ ❑ <br /> Secondary 91 g ❑ ❑ ❑ Fill Sump 87 Slave ® ❑ 1 ❑ ❑ <br /> STP Sump 87Mast/Syph g 1 ❑ ❑ ❑ Fill Sump 91 ® ❑ ❑ ❑ <br /> STP Sump 87 Syphon ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> STP Sump 87 Master N ❑ ❑ C ❑ ❑ ❑ ❑ <br /> STP Sump 87 Slave ® ❑ ❑ ❑ El ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water atter completion oftests: <br /> CERTIFICATIOeOF CIAN RESPONSIBLE FOR CONDUCTING TRIS TESTING <br /> To the best of my knowledge,tin tins document ar ccurate and in fuU compliance with legal requirements <br /> Date; June 2 3 , 2 015 <br /> Technician's Signature: <br />