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r <br />Secondary 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 />L FACILITY INFORMATInN <br />Facility Name: TOYS R US STOCKTON DISTRIBUTION Date of Testing: 08/26/2004 <br />Facility Address: 1624 ARMY COURT STOCKTON CA 95206 <br />Facility Contact: GLENN MAGAOY Phone: (209) 465-4912 <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agency Inspector (if present during testing): STEVEN C SHIH <br />2. TESTING CONTRACTOR INFORMATION S F P (1 9 2 n n A <br />Company Name: SHIRLEY ENVIRONMENTAL TESTING, L.L.C. <br />Technician Conducting Test: BRADLEY S LARSON HEALTH <br />PF -PA 1 <br />Credentials: ® CSLB Licensed Contractor ❑ SWRCB Licensed Tank Tester: <br />License Type: General A - Haz License Number: 814027 <br />Manufacturer Trainina <br />Manufacturer Component(s) Date Training Expires <br />VISUAL TEST <br />3. SUMMARY OF TEST RESULTS <br />• <br />. <br />DIESEL /.1 <br />BUCKET <br />■0 <br />■DO <br />000 <br />uuur■� <br />uuu� <br />0000 <br />0000 <br />voo <br />ovvo. <br />�■ <br />�oo <br />ur_�r■�r•� <br />ovvo <br />o�oo <br />ODr■�C■� <br />C7�0■ <br />Di <br />ovvo <br />0000 <br />over■� <br />0000 <br />v000� <br />o�oo <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />PRODUCT USED AND RETURNED TO TANK AFTER TESTING <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: BRADLEY S <br />Technician's Signature: <br />Date: 08/26/2004 <br />