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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 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:West valley Auto Services Date of Testing:03/05/2018 <br /> Facility Address:2615 West Grant Line Road <br /> Facility Contact:Rick Branchini Phone:925-699-1396 <br /> Date Local Agency Was Notified of Testing:02/12/2018 <br /> Name of Local Agency Inspector(f present during testing):None present <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name:Confidence UST Services <br /> Technician Conducting Test:Kyle Self <br /> Credentials: F]CSLB Licensed Contractor tv 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 /> ICC CA UST Service Technician 8485829 08/30/2018 <br /> INCON TS-STS 09/28/2018 <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Repairs Not Repairs <br /> Component Pass Fail Tested Made Component Pass Fail Tested Made <br /> 87 STP 0 ❑ ❑ ❑ Diesel fill sump ❑ ❑ ❑ <br /> 91 STP E ❑ ❑ ❑ UDC 1-2 ❑ ❑ ❑ <br /> Diesel STP 0 ❑ ❑ ❑ UDC 3-4 ❑ ❑ ❑ <br /> 87 secondary piping E ❑ ❑ 0 UDC 5-6 0 ❑ ❑ ❑ <br /> 91 secondary piping ❑ ❑ R UDC 7-8 E ❑ ❑ ❑ <br /> Diesel secondary piping ❑ ❑ ❑ UDC 9-10 ❑ E ❑ 1 ❑ <br /> 87 Vent secondary 0 ❑ ❑ ❑ UDC 11-12 ❑ Z ❑ ❑ <br /> 91 Vent secondary Z ❑ ❑ ❑ Vent Box 0 ❑ ❑ ❑ <br /> Diesel Vent secondary 2 ❑ ❑ ❑ 87-Vapor spill bucket z ❑ ❑ ❑ <br /> Vapor Return secondary 2 ❑ ❑ ❑ 91-Vapor spill bucket p ❑ ❑ ❑ <br /> 87 Fill sump D ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 91 Fill sump 0 ❑ ❑ ❑ I I ❑ ❑ ❑ ❑ <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 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: 0- Date:03/05/2018 <br />