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SWRCB,fanuary 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(f applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> FacilityName: CIRCLE K 2701205 1 DateofTesting: 10/14/2011 <br /> Facility Address: 16470 CAMBRIDGE @ LOUISE, LATHROP, CA, 95330 <br /> Facility Contact: ROBERT- PERMIT (N-206-1-4) Phone: (209) 858-4116 <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(if present during testing): THUY <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TANKNOLOGY, INC. <br /> Technician Conducting Test: TIMOTHY COULTER <br /> Credentials: 1fl CSLB Licensed Contractor ❑ SWRCB Licensed Tank Tester <br /> License Type: A—UT License Number: 5295244-734160 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> OPW SPILL BUCKETS 04/17/2012 <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Repairs Not Repai <br /> Component Pass Fail Tested Made Component Pass Fail Tested Made <br /> Spill Box 1 UNL FILL M El D 1:1 ❑ ❑ 1:1 E <br /> Spill Box 2 SUP FILL E El El El El El El <br /> El El El El El Ej <br /> El- <br /> El ElI El IEl Eli Eli El Q <br /> L1 El El El L El <br /> 0 El El El L El El I <br /> E] EJ Ej El EJ El I El I <br /> Ell El El E] El I ED I <br /> E El El Ej Ej Ej El I <br /> El El E E El El <br /> El El El El El El El El <br /> 10 0 El El El 0 <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> LEFT IN DRUM ON SITE. <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: 10/14/2011 <br />