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SWRCB, January 2002 Page 1 . 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 (f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. 1. FACILITY INFORMATION Facility Name: QUICK STUFF #7786 Pass Date of Testing: 06/24/2009 Facility Address: 10858 TRINITY PKWY @ 8 MILE WEST OF HWY 5, STOCKTON, CA, 95210 Facility Contact: MGR - DAVID COOPER Pass Phone: (209) 952-2213 Date Local Agency Was Notified of Testing : / / CSLB Licensed Contractor Name of Local Agency Inspector (if present during testing): GARRETT 2. TESTING CONTRACTOR INFORMATION Company Name: TANKNOLOGY, INC. Pass Fail Technician Conducting Test: KRISTOPHER BELL Component Pass Credentials: Not Tested CSLB Licensed Contractor Spill Box 3 DIE FILL SWRCB Licensed Tank Tester ❑ ❑ License Type: I License Number: 5 2 9 7 7 9 3 -UT ❑ ❑ Manufacturer Manufacturer Training Component(s) Date Training Expires PHILTITE INSTALATION El El D D E Ll 3. SUMMARY OF TEST RESULTS Component Pass Fail Not Tested Repairs Made Component Pass Fail Not Tested Repair: Made Spill Box 3 DIE FILL ❑ ❑ ❑ El ❑ ❑ ❑ 11 E El El D D E Ll 1:1 El El El El E El E D E E 1:1 1:1 D E] El El El 1:1 E Ll El El El F1 Ll 1:1 El L-1 D El F1 1:1 El El 1:1 1:1 El El El L] El El El El D El El 1:1 El El El El El El El El El El El El EJ I El D El El Ll EJ If hydrostatic testing was performed, describe what was done with the water after completion of tests: LEFT IN DRUM ON SITE 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: �� Date: 06/24/2009