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SWRCB,January2002 . . • Pagel of Secondary Containment Testing Report Form 10 .f Thisform is intendedfor use by contractors performing periodic testing of UST secondary containment systems. Use the appropriate pages of thisform to report resultsfor all components tested The completed form,written test procedures, and printouts from tests(if applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. 1. FACELITY INFORMATION Facility Name: KWIK SERV Date of Testing: 10-17-13 Facility Address: 824E YOSEMITE AVE MANTECA CA 95336 Facility Contacr. Phone: Date Local Agency Was Notified of Testing: Name of Local Agency Inspector(•¢•present during testing):NONE 2. TESTING CONTRACTOR INFORMATION Company Name: SST Technician Conducting Test: CFERRUCCI ENT Credentials: ❑CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester License Type: License NumberMEMNON: Manufacturer Training Manufacturer Component(s)) Date Training Expires INCON TS-STS 3. SUMMARY OF TEST RESULTS Component Pass Fail Not Repairs Comonent Pass Fail Not Repairs p Tested Made Tested Made REGULAR STP ❑ ❑ 0 ❑ REGULAR FILL ® ❑ ❑ ❑ PREMIUM STP 0 ❑ ❑ ❑ REGULAR VAPOR ® ❑ ❑ ❑ PLUSSTP 0 ❑ ❑ ❑ PLUS FILL ® ❑ ❑ ❑ REGULAR PROD SEC ❑ ❑ ® ❑ PLUS VAPOR ® ❑ ❑ ❑ PREMIUM PROD SEC ® 1 ❑ 1 ❑ ❑ PREMIUM FILL ® ❑ ❑ 1 ❑ PLUS PROD SEC ❑ ❑ 0 ❑ PREMIUM VAPOR ® ❑ ❑ ❑ REGULAR ANNULAR 0 ❑ ❑ ❑ ❑ ❑ ❑ ❑ PREMIUM/PLUS ANN. ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ DISPENSER�/2 0 ❑ ❑ ❑ ❑ ❑ ❑ ❑ DISPENSER% ❑ ❑ 0 ❑ ❑ ❑ ❑ ❑ DISPENSER 5/6 0 ❑ ❑ ❑ ❑ ❑ ❑ ❑ DISPENSER 7/8 ❑ ❑ ® ❑ ❑ ❑ ❑- ❑ If hydrostatic testing was performed,describe what was done with the water after completion of tests: WATER TAKEN OFF SITE AT TEST WATER CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING To the best of my knowledge,the cols stated In this document are accurate and in Jkll contpUance with legal requirements Technician's Sign Date: