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SWRCB, 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: TOYS "R" US Date of Testing: 09/04/2007 Facility Address: 1624 ARMY CT , STOCKTON, CA, 95297 Facility Contact: MANAGER Phone: (2 0 9) 465-4912 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: MATTHEW HASLEY Credentials: CSLB Licensed Contractor SWRCB Licensed Tank Tester License Type: I License Number: Manufacturer Manufacturer Training Component(s) Date Training Expires tanknologu all 06/29/2009 Secondary P. - 1 dslPiping 000 ��00 3. SUMMARY OF TEST RESULTS If hydrostatic testing was performed, describe what was done with the water after completion of tests: 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: d, � Date: 09/04/2007 000 ��00 Secondary P. - 1 dslPiping 000 ��00 Sump 1 000 ��00 000 ��00 000 ��OOI! 000 ��00 If hydrostatic testing was performed, describe what was done with the water after completion of tests: 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: d, � Date: 09/04/2007