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SWRCB,January 2002 �/ Page 1. <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/operatorfor submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> FacilityName: CIRCLE K 2701205 1 Dateof Testing: 09/29/2009 <br /> Facility Address: 16470 CAMBRIDGE O 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 I 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 <br /> Made <br /> Secondary Pipe 1 UNL REG [fl ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Secondary Pipe 2 SUP SUP E E-10 <br /> ❑ ❑ ❑ ❑ ❑ ❑ <br /> Piping Sump 1 UNL [E ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Piping Sump 2 SUP E-] <br /> 1-1 Ej El El ❑ 1:1 <br /> UDC 1/2 X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> UDC 3/4 El ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> EJ Ej El El El El Ej <br /> Ll Ej E1 Q <br /> Q El El <br /> E El El El El El El <br /> Ej El Ej El E El <br /> Ej <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, the facts stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: ^' Date: 09/29/2009 <br />