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SWRCB, January 2002 Page 1 . Second; � Containment Testing Rep 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 Facility Name: TOYS "R" US Date of Testing: 11/03/2006 Facility Address: 1624 ARMY CT , STOCKTON, CA, 95297 Facility Contact: MANAGER Phone: (2 0 9) 465 - 4 912 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: RAYMOND SIMMS Credentials: CSLB Licensed Contractor E1 SWRCB Licensed Tank Tester License Type: I License Number: Manufacturer Manufacturer Training Component(s) Date Training Expires _ ��OOII 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: Date: 11/03/2006 Spill Box 1 DIE FILL000 ��OO 000 _ ��OOII 000 ��00 000 ��00 000 ��00 0000 ��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: Date: 11/03/2006