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. SWRCTZ, January 2002 Page 1. <br />Secondary Containment Testing Rep rt 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: TOYS "R" US <br />Date of Testing: 09/04/2007 <br />Facility Address: 1624 ARMY CT , STOCKTON, CA, 95297 <br />Facility Contact: MANAGER <br />Phone: (2 0 9) 465 - 4 912 <br />Date Local Agency Was Notified of Testing: 08/29/2007 <br />Name of Local Agency Inspector (if present during testing): <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: TANKNOLOGY , <br />INC. <br />Technician Conducting Test: MATTHEW HASLEY <br />Credentials: <br />CSLB Licensed Contractor <br />SWRCB Licensed Tank Tester <br />License Type: A <br />Tank Annular 1 <br />I License Number: 743160 <br />Manufacturer <br />Manufacturer Training <br />Component(s) <br />Date Training Expires <br />tanknologu <br />all <br />06/29/2009 <br />- .. _ Pipe <br />0000 <br />��00 <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: t, &L Date: 09/04/2007 <br />Tank Annular 1 <br />- .. _ Pipe <br />0000 <br />��00 <br />.. <br />000 <br />��00 <br />.. <br />o00o <br />a000 <br />0000 <br />0000 <br />0000 <br />0000 <br />0000 <br />0000 <br />0000 <br />0000 <br />0000 <br />0000 <br />0000 <br />0000 <br />0000 <br />0000 <br />a000 <br />0000 <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: t, &L Date: 09/04/2007 <br />