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SWRCB,January 2002 Page 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(if applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. 1. FACILITY INFORMATION Facility Name:Fast&Easy#103 Date of Testing:07/18/2018 Facility Address:8660 Lower Sacramento Rd Facility Contact:Asim Phone:707-393-9856 Date Local Agency Was Notified of Testing:07/10/2018 Name of Local Agency Inspector(fpresent during testing): 2. TESTING CONTRACTOR INFORMATION Company Name:Confidence UST Services Technician Conducting Test:Frank Amest0 Credentials: 0 CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester License Type:A, Haz, C-61 D-40 License Number:804904 Manufacturer Training Manufacturer Component(s) Date Training Expires ICC use service technicians 10/25/2019 INCON TS-STS 01/19/2020 3. SUMMARY OF TEST RESULTS Component Pass Fail Not Repairs Component Pass Fail Not Repairs Tested Made Tested Made Diesel annular 0 ❑ ❑ ❑ UDC 7/8 0 ❑ ❑ ❑ 91 annular 0 ❑ ❑ ❑ 91 vapor bucket 0 ❑ ❑ ❑ 87 annular 0 ❑ ❑ ❑ 87 vapor bucket k] ❑ ❑ ❑ Diesel secondary piping 0 ❑ ❑ ❑ ❑ ❑ ❑ ❑ 91 secondary piping 0 ❑ ❑ ❑ ❑ ❑ ❑ ❑ 87 secondary piping 0 ❑ ❑ ❑ ❑ ❑ ❑ ❑ Diesel STP 0 ❑ ❑ ❑ ❑ ❑ ❑ ❑ 91 STP r❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ 87 STP ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ UDC 1/2 0 ❑ ❑ ❑ ❑ ❑ ❑ ❑ UDC 3/4 0 ❑ ❑ ❑ ❑ ❑ ❑ ❑ UDC 5/6 0 ❑ ❑ ❑ ❑ ❑ ❑ ❑ If hydrostatic testing was performed,describe what was done with the water after completion of tests: CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING To the best of my knowledge,the,facts stated in this document are accurate and in full compliance with legal requirements Technician's Signature: 1 Date:07/18/2018