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SWRCB, January 2002 <br />Secondary Containment Testing Report Form <br />Page 1 of <br />This form is intended for use by contractors performing periodic testing of UST 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 owner/operator for submittal to the local regulatory agency. <br />1. FACTT,TTV INFORMATION <br />Facility Name: ARP Mini Mart Date of Testing: 01/10/2018 <br />Facility Address: 25775 Patterson Pass Rd <br />Facility Contact: Nick Phone: <br />Date Local Agency Was Notified of Testing :12/21/2017 — <br />EE IN i )NII Ei\! T- <br />Name of Local Agency Inspector (if present during testing): Aaron Hang <br />❑ SWRCB Licensed Tank Tester <br />2. TESTING CONTRACTOR INFORMATION MAR 0 J 2018 <br />Company Name: Confidence UST Services, Inc. <br />Pass <br />Technician Conducting Test: Kyle Self <br />Not <br />Tested <br />EE IN i )NII Ei\! T- <br />Credentials: 0 CSLB Licensed Contractor <br />❑ SWRCB Licensed Tank Tester <br />n �,-D/\�T", TENT <br />License Type: A-Haz, C61 -D40 <br />Repairs <br />Made <br />License Number: 804904 <br />0 <br />Manufacturer <br />Manufacturer Traininz <br />Component(s)) <br />Date Training Expires <br />ICC <br />CA UST Service Technician (8485829) <br />10/28/2018 <br />I NCON <br />TS -STS <br />11/08/2018 <br />0 <br />❑ <br />❑ <br />❑ <br />91 fill sump <br />0 <br />3_ SUMMARY OF TF,ST RF.SITI,TS <br />Component <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />Component <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />Annular 91 <br />0 <br />❑ <br />❑ <br />❑ <br />87 slave stp sump <br />0 <br />❑ <br />❑ <br />❑ <br />Annular 87-1 <br />0 <br />❑ <br />❑ <br />❑ <br />91 fill sump <br />0 <br />❑ <br />❑ <br />❑ <br />Annular 87-2 <br />® <br />1 ❑ <br />❑ <br />❑ <br />87-1 fill sump <br />0 <br />❑ <br />❑ <br />❑ <br />Annular 87 slave <br />0 <br />❑ <br />❑ <br />❑ <br />87-2 fill sump <br />0 <br />❑ <br />❑ <br />❑ <br />91 Product secondary <br />0 <br />❑ <br />❑ <br />❑ <br />87 slave fill sump <br />0 <br />❑ <br />❑ <br />❑ <br />87-1 Product secondary <br />0 <br />❑ <br />❑ <br />❑ <br />91 fill spill bucket <br />0 <br />❑ <br />❑ <br />❑ <br />87-2 Product secondary <br />0 <br />1 ❑ <br />❑ <br />❑ <br />91 vapor spill bucket <br />0 <br />❑ <br />❑ <br />❑ <br />87-2 Product siphon secondary <br />® <br />1 ❑ <br />❑ <br />❑ <br />87-1 fill spill bucket <br />0 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />87 -1 vapor spill bucket <br />0 <br />❑ <br />❑ <br />❑ <br />91 stp sump <br />0 <br />❑ <br />❑ <br />❑ <br />87-2 fill spill bucket <br />0 <br />❑ <br />❑ <br />❑ <br />87-1 stp sump <br />0 <br />❑ <br />❑ <br />❑ <br />87-2 vapor spill bucket <br />0 <br />❑ <br />❑ <br />❑ <br />187-2 stp sump <br />0 <br />❑ <br />❑ <br />❑ <br />87 slave fill spill bucket <br />0 <br />1 ❑ <br />❑ <br />❑ <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />Nater was hauled off by Confidence UST Services. <br />CERTIFICATION OF TECHNICIAN <br />To the best of my knowledge, the facts stated in this d <br />Technician's Signature: <br />FOR CONDUCTING THIS TESTING <br />are acc ratefull compliance with legal requirements <br />Date: 01/10/2018 <br />