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SWRCB, January 2002 <br />Page 1 of <br />Secondary Containment Testing Report Form <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 ownerioperator for submittal to the local regulatoy agency. <br />1. FACILITY 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 />Name of Local Agency Inspector (if present during testing): Aaron Hang <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: Confidence UST Services, Inc. tNVIHONMENIAL <br />Technician Conducting Test: Kyle Self <br />DEPAR <br />Credentials: El CSLB Licensed Contractor <br />❑ SWRCB Licensed Tank Tester <br />License Type: A-Haz C6I-D40 <br />License Number: 804904 <br />Manufacturer <br />Manufacturer Training <br />Com onent(s) Date Training Expires <br />ICC <br />CA UST Service Technician (8485829) 10/28/2018 <br />I NCON <br />TS -STS 11/08/2018 <br />❑ <br />❑ <br />87 slave stp sump <br />0 <br />3. SUMMARY OF TEST RESULTS <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 />0 <br />❑ <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 />❑ <br />❑ <br />❑ <br />91 vapor spill bucket <br />0 <br />❑ <br />❑ <br />❑ <br />87-2 Product siphon secondary <br />0 <br />❑ <br />❑ <br />❑ <br />87-1 fill spill bucket <br />0 <br />D <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 />87-2 stp sump <br />0 <br />❑ <br />❑ <br />❑ <br />87 slave fill spill bucket <br />0 <br />❑ <br />❑ <br />❑ <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />Water was hauled off by Confidence UST Services. <br />CERTIFICATION OF TECHNICIAN <br />To the best of my knowledge, the facts stated in this a <br />FOR CONDUCTING THIS TESTING <br />are acc rate fall compliance with legal requirements <br />Technician's Signature: V 01Z Date: 01/10/2018 <br />