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SWRCB, January 2002 RECEIVED 0CTajff7—Nff Secondary Containment Testing Report For VI R� RENTA LThisform is intendedfor use by contractors performing periodic testing of UST secondary containment appropriate pages ofthisform to report resultsfor all components testedThe comPletedform, written test procedures, anMENT printouts from tests (f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. 1. FACILITY INFORMATION l,'aciIity Name: Toys R Us I Date of Testing: 9/24/2013 Facility Address: 1624 Army Court, Stockton, Ca. 95206 Facility Contact: Tony Evens I Phone: (209) 465-4912 Date Local Agency Was Notified of Testing: 8/26/2013, by Afford -A -Test Name of Local Agency Inspector (f present during testing): 2. TESTING CONTRACTOR INFORMATION Company Name: R&D Compliance Testing Technician Conducting Test: Benjamin F. Duncan Jr. Credentials: ❑ CSLB Licensed Contractor X SWRCB Licensed Tank Tester License Type: Tank Tester License Number: 90-11201ICC #5246802 -UT Manufacturer Trainine Manufacturer Component(s) Date Training Expires 3. SUMMARY OF TEST RESULTS Component Pass Fail Not Tested Repairs Made Component Pass Dail Not Tested Repairs Made Annular Tank X ❑ ❑ ❑ ❑ ❑ ❑ ❑ Secondary Pipe X ❑ ❑ ❑ ❑ ❑ ❑ Piping Sump X ❑ ❑ ❑ ❑ 1 ❑ ❑ 1 ❑ Dispenser Sump X ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ 1 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ If hydrostatic testing was performed, describe what was done with the water after completion of tests: Test Fluid Supplied and recovered for reuse by, R&D Compliance Testing. 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: September 24, 2013