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SWRCB, January 2002 <br />Page 1. <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: QUICK STUFF #7789 <br />DateofTesting: 11/13/2007 <br />Facility Address: 10858 TRINITY PKWY , STOCKTON, CA, 95210 <br />Facility Contact: MGR - DAVID COOPER <br />Phone: (2 0 9) 952 - 22 13 <br />Date Local Agency Was Notified of Testing: / / <br />Name of Local Agency Inspector (if present during testing): GARRETT BACKUS <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: TANKNOLOGY , INC. <br />Technician Conducting Test: <br />KELVIN CRUZ <br />Credentials: <br />CSLB Licensed Contractor SWRCB Licensed Tank Tester <br />License Type: SPILL BKT <br />License Number: 5254041 -UT <br />Manufacturer <br />Manufacturer Training <br />Component(s) <br />Date Training Expires <br />PHIL TITE <br />SPILL BKT <br />03/01/2008 <br />Spill Box 2 PRE FILL <br />3. SUMMARY OF TEST RESULTS <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <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: �� Date: 11/13/2007 <br />Spill Box 2 PRE FILL <br />Spill Box 3 DIE FILL <br />000 <br />��00 <br />000 <br />��00 <br />000 <br />��00 <br />000 <br />��00 <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <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: �� Date: 11/13/2007 <br />