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SWRC13, 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 (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. 1. FACILITY INFORMATION FacilityName: QUICK STUFF #7789 DateofTesting: 10/17/2008 Facility Address: 10858 TRINITY PKWY , STOCKTON, CA, 95210 Facility Contact: MGR - DAVID COOPER Phone: (209) 952-2213 Date Local Agency Was Notified of Testing : / / Name of Local Agency Inspector (if present during testing): 2. TESTING CONTRACTOR INFORMATION Company Name: TANKNOLOGY , INC. Technician Conducting Test: KENNETH LEE Credentials: CSLB Licensed Contractor SWRCB Licensed Tank Tester License Type: VEETEROOT I License Number: B 3 613 0 Manufacturer TraininE Manufacturer Component(s) Date Training Expires Spill Box 2 PRE FILL 3. SUMMARY OF TEST RESULTS If hydrostatic testing was performed, describe what was done with the water after completion of tests: PUT 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 ffdl compliance with legal requirements Technician's Signature: / Date: 10/17/2008 Spill Box 2 PRE FILL 00m� ��00 W0=0 ��00 If hydrostatic testing was performed, describe what was done with the water after completion of tests: PUT 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 ffdl compliance with legal requirements Technician's Signature: / Date: 10/17/2008