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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 LIST 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 ownerv'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:5000 East 2nd Street <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(rf present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name:Confidence UST Services <br /> Technician Conducting Test:Frank AmeStO <br /> Credentials: ?-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 /> 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 o ❑ ❑ ❑ UDC 5/6 0 ❑ ❑ ❑ <br /> 87 annular Z ❑ ❑ ❑ UDC 7/8 0 ❑ ❑ ❑ <br /> 87 secondary piping0 ❑ ❑ ❑ 87 vapor bucket C ❑ ❑ ❑ <br /> 91 n secondary piping0 ❑ ❑ ❑ 91 n vapor bucket ❑ 0 ❑ ❑ <br /> 91s secondary piping0 ❑ ❑ ❑ 91 s vapor bucket 2 ❑ ❑ ❑ <br /> diesel secondary piping0 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 87 STP 0 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 91 n STP 0 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 91 s STP 0 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> diesel STP o ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> UDC 1/2 0 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> UDC 3/4 0 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <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: 6� (X - <br /> Date:05/24/2018 <br />