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RECEIVED <br />h" L� d 2016 <br />Secondary Containment Testing Report For EwRON'EN'', L <br />This form is intended for use by contractors performing periodic testing of UST secondary containment syster pl � C S TF{ <br />appropriate pages of thisform to report results for all components tested. The completed form, written test procedures, an <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 />2. TESTING CONTRACTOR INFORMATION <br />Company Name: B.Z. Service Station Maintenance <br />Technician Conducting Test: JOHN LI <br />87 SECONDARY PROD <br />Credentials: ® CSLB Licensed Contractor <br />❑ SWRCB Licensed Tank Tester <br />License Type: ICC <br />Manufacturer <br />License Number: 433159 <br />Manufacturer Trainina <br />Component(s) Date Training Expires <br />INCON <br />TS -STS MAR 2018 <br />91 STP <br />DSL STP <br />❑ <br />DSL ANNULAR Ell <br />3. SUMMARY OF TEST RESULTS <br />Component Pass Fail Not Repairs Component Pass Fail <br />Tested Made <br />Not Repairs <br />Tested Made <br />87 SECONDARY PROD <br />91 SECONDARY PROD <br />DSL SECONDARY PROD <br />87 STP <br />91 STP <br />DSL STP <br />❑ <br />DSL ANNULAR Ell <br />❑ <br />UDC 1/2 <br />UDC 3/4 <br />❑ IEJ <br />UDC 5/6 0 EJ <br />UDC 7/8 <br />UDC 9/10 <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />TOOK AS TEST WATER <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 jkll compliance with legal requirements <br />Technician's Signature: Date: 11/8/2016 <br />Secondary Containment Test Results 1 of 7 <br />