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04/19/05 TUE 09:30 FAX 9512705121 CIRCLE K STORES U004 <br /> S WRCB,January 2002 Page I of Ile <br /> Secondary Containment Testing Report Form <br /> This form is intendedfor use by contractors perfoming periodic testing of UST secondary containment systems. Use the <br /> appropriate pages of thisform to report resultsfor all components tested The completed form,written test procedures,and <br /> prinioutrfrom tests(iapplicable),should be provided to the facility owner/operatorfor submittal to the loco/regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: jr Date of Testing: ?-Ze/—0 t4 <br /> Facility Address: rj GtN Ca <br /> Facility Coatact t Phone: Circle K- #2701205 <br /> DateLocalAgemyWasNotifiedofTesting: 16470 Cambridge Dr <br /> Natne of Local Agency Inspector(tfpreseat during testing): Lathrop, CA 95330 <br /> 2. TESTING CONTRACTOR INFORMATION N04312 —SB 989 testing _ <br /> Company Name: ; �'-� Iv c.. <br /> Technician Conducting Test onj --- <br /> Credentials: VCSLB Licensed Contractor D SWRCB Licensed Tank Tester <br /> License Type: (' w l D 0 HA-2= License Number. 3 003 <br /> Manufacturer Trainine <br /> Manufacturer Components) Date Tminina E ims <br /> kutyn H ed m <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail .I.of Repairs Component Pass Fail Not Repairs <br /> Tested Mnde <br /> fi N ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> r h ❑ 11 0 D D <br /> ❑ ❑ -W ❑ ❑ ❑ ❑ ❑ <br /> 02 <$ ❑ ❑ ❑ ❑ ❑ ❑ D <br /> ❑ ❑ ❑ ❑ D ❑ ❑ <br /> G x D ❑ ❑ ❑ ❑ ❑ ❑ <br /> _cy it ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 1 `I a-F t8' ❑ ❑ ❑ ❑gil ❑ <br /> 91 w FI ❑ ❑ ❑ ❑0 D <br /> 91 ❑ Li 11 ❑ ❑ <br /> If hydrostatic testing was performed,descnbe what was done with the water after completion of tests: <br /> J u h$.�n . <br /> CERTIFICATION OF TECMMCIAN RESPONSIBLE FOR CONDUCTING TMS TESTING <br /> To the best of my knowledge the fads stated as this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: id� ,, /� - Date: ` -Pi-0`/ <br /> Circle K - #2701205 <br /> 16470 Cambridge Dr <br /> Lathrop, CA 95330 <br /> N04312 —SB 989 testing <br />