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SWRCB, January 2002 Page 2 of Secondary Containment Testing Report Form This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the appropriate pages of this form to report results for all components tested. The completed form, written test procedures, and printouts from tests (f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. 1. FACILITY INFORMATION Facility Name: ARP Mini Mart Date of Testing: 01/10/2018 Facility Address: 25775 Patterson Pass Rd Facility Contact: Nick Phone: Date Local Agency Was Notified of Testing :12/21/2017 Name of Local Agency Inspector (if present during testing): Aaron Hang 2. TESTING CONTRACTOR INFORMATION Company Name: Confidence UST Services, Inc. Technician Conducting Test: Kyle Self Fail Credentials: ❑ CSLB Licensed Contractor ❑ SWRCB Licensed Tank Tester License Type: A-Haz, C61 -D40 Fail License Number: 804904 Manufacturer Manufacturer Training Component(s) Date Training Expires ICC CA UST Service Technician (8485829) 10/28/2018 I NCON TS -STS 11/08/2018 ❑ ❑ ❑ ❑ 3. SUMMARY OF TEST RESULTS Component Pass Fail Not Tested Repairs Component Made Pass Fail Not Tested Repairs Made 87 slave vapor spill bucket 0 ❑ ❑ ❑ ❑ ❑ ❑ ❑ UDC 1-2 0 ❑ ❑ ❑ ❑ ❑ ❑ ❑ UDC 3-4 0 ❑ ❑ ❑ ❑ ❑ ❑ ❑ UDC 5-6 0 ❑ ❑ ❑ ❑ ❑ ❑ 1 ❑ UDC 7-8 0 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ 0 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ 1 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ 1 ❑ 1 ❑ ❑ If hydrostatic testing was performed, describe what was done with the water after completion of tests: CERTIFICATION OF TECHNICIAN RESPONSIB To the best of my knowledge, the facts stated i000s docu0y pw ar7 CONDUCTING THIS TESTING Fid in full compliance with legal requirements Technicians Signature: g / y Date: 01/10/2018