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SWRCB,January 2002 Page I of 3 Secondary Containment Testing Report Form This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the appropriate pages of this form to report results for all components tested. The completed form,written test procedures,and printouts from tests(if applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. I. FACILITY INFO TION Facility Name:circle K Date of Testing:i t/t8rmto Facility Address:1403 Country Club Blvd-Stockton,CA 95204 Facility Contact:Site Attendant Phone:209-943.2082 Date Local Agency Was Notified of Testing: Name of Local Agency Inspector(cfpresent during testing): 2. TESTING CONTRACTOR INFORMATION Company Name:Getder-Ryan Inc Technician Conducting Test:Jim Reed Credentials: 9 CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester License Type:A,B,C10,C57,D40,HAZ License Number:220793 Manufacturer Training Manufacturer Co ovens Date Trainin Ex ires Incon - Incon Sump Tester - 06/22/2011 UST Service Tech 3. SUNEWARY OF TEST RESULTS Component Pass Fail Not Repairs Component Pass Fail Not Repairs Tested Made Tested Made 87 Secondary Line 0 ❑ ❑ ❑ ❑ ❑ ❑ ❑ Waste Oil Secondary 9 ❑ ❑ ❑ ❑ ❑ ❑ ❑ Waste Oil Vent ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ UDC 5/6 N I ❑ ❑ ❑ ❑ ❑ ❑ ❑ UDC 7/8 P9 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ 1 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ 0 ❑ ❑ ❑ ❑ ❑ ❑ 1 ❑ ❑ ❑ ❑ ❑ ❑ If hydrostatic testing was performed,describe what was done with the water after completion of tests: CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING To the best of my knowledge,the is stated in this document are accurate and in full compliance with legal requirements Technician's Signature: �� Date:11/18/2010 t