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SWRCB, January 2002 Page —_ of 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 completedform, written test procedures, and printouts from tests (tfapplicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. 1. FACILITY INFORMATION Facility Name: Toys R Us Date of Testing: 9/27/10 Facility Address: 1624 Army Court, Stockton Ca 95206 Facility Contact: Glen I Phone: 209-4654912 Date Local Agency Was Notified of Testing: 9/15/10 Name of Local Agency Inspector (if present during testing): 2. TESTING CONTRACTOR INFORMATION Company Name: JP Petroleum Service Technician Conducting Test: Gabe Garcia Credentials: x CSLB Licensed Contractor ❑ SWRCB Licensed Tank Tester License Type: A License Number: 811471 ICC # 5281582 Manufacturer Manufacturer Training Component(s)) Date Training Expires ©o©a i o000 3. SUMMARY OF TEST RESULTS If livdrostatic testing was performed, describe what was done with the water after completion of tests: Water was filtered and returned to holding tank. CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING To the best of my knowledge, the at d in this doc 1 are accuquie and in full compliance with legal requirements Technicians Signature: _ �/ Date: ©o©a o000 ©000 0000 ©000 0000 MOM oo 0000 000 0000 000 . 0000 000 0000 mom� oaoo 000 ----- - -®o�■o 000 If livdrostatic testing was performed, describe what was done with the water after completion of tests: Water was filtered and returned to holding tank. CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING To the best of my knowledge, the at d in this doc 1 are accuquie and in full compliance with legal requirements Technicians Signature: _ �/ Date: