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SWRCB, January 2002 0 0 Page 1. 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. 1. FACILITY INFORMATION FacilityName: COUNTRY SIDE MINI MART DateofTesting: 04/04/2007 Facility Address: 14971 N HWY 88 , LODI, CA, 95240 Facility Contact: GARY BURG IN Phone: (2 0 9) 368-5380 Date Local Agency Was Notified of Testing Name of Local Agency Inspector (if present during testing): 2. TESTING CONTRACTOR INFORMATION Company Name: TANKNOLOGY , INC. Technician Conducting Test: HEATH MCEVER Credentials: CSLB Licensed Contractor ❑ SWRCB Licensed Tank Tester License Type: I License Number: ��00 Manufacturer Manufacturer Training Component(s) Date Training Expires Spill Box 2 SUP FILL Box 3 DIE FILL0000_ 3. SUMMARY OF TEST RESULTS 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 facts stated in this document are accurate and in full compliance with legal requirements Technician's Signature: x Date: 04/04/2007 Spill Box 1 UNL FILLSpill 0000 ��00 Spill Box 2 SUP FILL Box 3 DIE FILL0000_ ��00 0000 ��00 _000 ��00 000 ��00 000 ��00 0000 ��00 0000 ��00 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 facts stated in this document are accurate and in full compliance with legal requirements Technician's Signature: x Date: 04/04/2007