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Secondary Containment Testing Report Form JAN 0 7 2,016 This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the appropriate pages o� f'this form to report results for all components tested. I he completed fortn written test prod n r i printouts from tests (if applicable), should be provided to the facility owner/operator for submittal to the local regi$ 1 11? A r" rry rnt1WnuNr a •rrnv Facility Name: Escalon Mini Mart Date of Testing: 12.31.2015 Facility Address: 1097 E. Yosemite - Escalon, Ca. WO# 153718 Time: 9:00am Facility Contact: Bill Phone: 209-838-1546. Date Local Agency Was Notified of Testing: Name of Local Agency Inspector (zfpresent during testing): 2_ TESTING CONTRACTOR INFORMATION Component Pass Fail Not Repairs Component Tested Made Pass Fail Not Tested Regains Made 87/91 Ann. Space X ❑ ❑ ❑ ❑ ❑ ❑ ❑ 87 Secondary Line X ❑ ❑ ❑ ❑ ❑ ❑ ❑ 91 Secondary Line X ❑ ❑ ❑ ❑ 1 ❑ 0 ❑ 87 STP X ❑ ❑ ❑ ❑ ❑ 1 ❑ 1 ❑ 91 STP X ❑ ❑ ❑ ❑ ❑ 1 ❑ ❑ 1/2 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ 3/4 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ 5/6 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ 7/8 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ El ❑ ❑ ❑ If hydrostatic testing was performed, describe what was done with the water after completion of tests: All pumped out and stored into SB 989 trailer for next use. CERTIFICATION OF ECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING To the best of my knowledge, the fa stated in this document are accurate and in full compliance with legal requirements Technician's Signature: 4°"'n__ Date: 12.31.2015.