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SWRCB, January 2002 <br />Page 2 of <br />Secondary Containment Testing Report Form <br />This form is intended for use by contractors pe{forming 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. 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. <br />Technician Conducting Test: Kyle Self <br />Credentials: ❑ CSLB Licensed Contractor <br />❑ SWRCB Licensed Tank Tester <br />License Type: A-Haz C61 -D40 <br />License Number: 504904 <br />Manufacturer <br />Manufacturer Trainins <br />Com onent(s) Date Training Expires <br />ICC <br />CA UST Service Technician (8485829) 10/28/2018 <br />INCON <br />TS -STS 11/08/2018 <br />3. SUMMARY OF TEST RESULTS <br />I Component <br />Component <br />87 slave vapor spill bucket <br />0000 <br />a000� <br />0000 <br />0000 <br />0000 <br />0000 <br />0000 <br />0000 <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />CERTIFICATION OF TECHNICIAN RESPONSIB <br />To the best of my knowledge, the facts stated ii>4s docgjp_* t aSA <br />CONDUCTING THIS TESTING <br />Fid in fill compliance with legal requirements <br />Technician's Signature: / /i// Date: 01/10/2018 <br />