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SWRCB,January 2002 %WW .1.10 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(ifapplicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> FacilityName: CIRCLE K 2701205, MKT #2616 (11-206) Dateof Testing: 11/14/2008 <br /> Facility Address: 16470 CAMBRIDGE , 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: RHOME DESBIENS <br /> Credentials: ❑ CSLB Licensed Contractor ❑ SWRCB Licensed Tank Tester <br /> License Type: License Number: <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Repairs Not Repair <br /> Component Pass Fail Tested Made Component Pass Fail Tested Made <br /> Spill Box 1 UNL FILL ff] ❑ ❑ ❑ D El E El <br /> Spill Box 2 SUP FILL [11 ❑ ❑ ❑ ❑ 1:1 El <br /> El- <br /> El El El El El El Q <br /> El- <br /> El Ej El El . El <br /> E El E <br /> ❑ I ❑ I ❑ I ❑ I Ell Ell ❑ <br /> 11 El <br /> I] EEE] <br /> ED El El Q <br /> E � � El <br /> El El El 01 � E <br /> ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> CERTIFICATION OF TECM'4ICLAN 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: 11/14/2008 <br />