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SWRC13,January 2002 Page 1. <br /> Seconeary 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 completedform, written testprocedures, and <br /> printouts from tests(iapplicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: CIRCLE K 2701205 1 Dateof Testing: 09/29/2009 <br /> Facility Address: 16470 CAMBRIDGE @ LOUISE, LATHROP, CA, 95330 <br /> Facility Contact: MANAGER-ROBERT Phone: (209) 858-4116 <br /> Date Local Agency Was Notified of Testing: / / <br /> Name of Local Agency Inspector(if present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TANKNOLOGY, INC. <br /> Technician Conducting Test: JARROD COOKE <br /> Credentials: ❑X CSLB Licensed Contractor ❑ SWRCB Licensed Tank Tester <br /> License Type: a License Number: 743160 <br /> Manufacturer Trainine <br /> Manufacturer Component(s) Date Training Expires <br /> tanknology all 07/17/2011 <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Repairs Not Repair <br /> Component Pass Fail Tested Made Component Pass Fail Tested Made <br /> Secondary Pipe 1 UNL REG IKI ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Secondary Pipe 2 SUP SUP Ifl 1:1 1:1 ❑ ❑ ❑ ❑ ❑ <br /> Piping Sump 1 UNL E ❑ ❑ ❑ ❑ ❑ ❑ El- <br /> Piping <br /> Piping Sump 2 SUP x ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> UDC 1/2 x ❑ ❑ ❑ ❑ ❑ ❑ El- <br /> UDC <br /> UDC 3/4 El ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ D 1 Ell ❑ <br /> E] El E El El EJ <br /> El EJ El El I Ell El EJ <br /> Ej EJ El E El <br /> 1E] JE11 ❑ ❑ I ❑ ❑ ❑ ❑ <br /> El <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> taken water dog <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge, thefacts stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: �G^�^L' Date: 09/29/2009 <br />