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' SWRCB, January 2002 Page 1. <br />Second ty 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: TOYS "R" US <br />Date of Testing: 09/07/2007 <br />Facility Address: 1624 ARMY CT , STOCKTON, CA, 95297 <br />Facility Contact: MANAGER <br />Phone: (2 0 9) 465-4912 <br />Date Local Agency Was Notified of Testing <br />Name of Local Agency Inspector (if present during testing): RAY VON FLUE <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: TANKNOLOGY , INC. <br />Technician Conducting Test: DOUGLAS HARTY <br />Credentials: ❑ CSLB Licensed Contractor <br />SWRCB Licensed Tank Tester <br />License Type: SERVICE TECH <br />License Number: 5244407 -UT <br />Manufacturer Training <br />Manufacturer Component(s) <br />Date Training Expires <br />OPw EVR <br />12/16/2007 <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: 09/07/2007 <br />Spill Box 1 DIE FILL <br />0000 <br />��00 <br />000 <br />��00 <br />0000 <br />��00 <br />0000 <br />��00 <br />0000 <br />a000 <br />0000 <br />0000 <br />0000 <br />0000 <br />a000 <br />0000 <br />0000 <br />0000 <br />0000 <br />0000 <br />0000 <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: Date: 09/07/2007 <br />