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SWRCB , January 2002 Page of <br /> Secondary Containment Testing Report Form <br /> This form is intended,for use by contractors perfor•rrrirrg periodic testing of UST secondary containment systems. Use the <br /> appropriate pages of this farm to report results for all components tested. The completed form, written test procedures, and <br /> printouts froom 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 I 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 dining testing) : <br /> 2 . TESTING CONTRACTOR INFORMATION <br /> Company Name : Confidence UST Services <br /> Technician Conducting Test: Frank Amesto <br /> Credentials : R1 CSLB Licensed Contractor �1 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 /> ICC can use service technician 10/25/2019 <br /> INCON TS - STS 01 / 19/2020 <br /> 3 . SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> 91n/91s/ DSL annular D ❑ ❑ ❑ UDC 5/6 ❑ ❑ ❑ <br /> 87 annular ❑ ❑ ❑ UDC 7/8 ❑ ❑ ❑ <br /> 87 secondary piping ❑ ❑ ❑ 87 vapor bucket D 1 ❑ ❑ ❑ <br /> 91n secondary piping 0 ❑ ❑ ❑ 91 n vapor bucket ❑ 0 ❑ ❑ <br /> 91s secondary piping o ❑ ❑ ❑ 91 s vapor bucket 0 ❑ ❑ ❑ <br /> diesel secondary piping o ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 87 STP ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 91 n STP 0 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 91 s STP D ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> diesel STP D ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> UDC 1 /2 0 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> UDC 3/4 0 El El El El 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 fill compliance with legal requirements <br /> `"` �� ' —' te: 05/24/2018 <br /> Technicians Signature : a <br /> D <br />