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• 0 It Page 1 of 3 R !Ex �` Secondary Containment Testing Report Form J, This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the�� EC ' �01 appropriate pages of this form to report results for all components tested. The completed farm, written test procedures, and printouts from tests (f applicable), should be provided to the facility owner/operator for submittal to the local regAMROWWTAL HEAEI 1. FACILITY INFORMATION PERMIT/SEWCES Facility Name: Fast and Easy #60 Date of Testing: 12/13/2011 Facility Address: 1087.8 N Highway 99 Frontage Road, Stockton, CA 95212 Facility Contact: Mike All I Phone: (707) 747-2958 [Z SWRCB Licensed Tank Tester Date Local Agency Was Notified of Testing: 12105/2011 License Number: 958763 Name of Local Agency Inspector (if present during testing): Caldwell Instruments, Inc. 2. TESTING CONTRACTOR INFORMATION Company Name: ECO-CHEK Compliance Technician Conducting Test: Nik Zagorov Credentials: ® CSLB Licensed Contractor [Z SWRCB Licensed Tank Tester License Type: A License Number: 958763 Manufacturer Training Manufacturer Component(s)) Date Training Expires Caldwell Instruments, Inc. Level Change Indicator NIA �00■ �■ �0� 3. SUMMARY OF TEST RESULTS Component 1. ■00�■ 0■ �00■ �■ �0� �■ 000■ 0■0■00■ 0■0■0� DD 1001 DDDR 0■�■0■ 0■ '� 0■0■0■ 0 ■��■0■ 0■ 0■0■0■ 0 0�■ 0■ 0 00■ 0■ 0■ 0■0■0■ 0■ 00■0� �■ ■DO■ 0■ 0■ �0■ ■00■ 00 �■ ©00 00■ 0■ 0 0■ ■00© 1��■ DD �OQO■ If hydrostatic testing was performed, describe what was done with the water after completion of tests: Placed in a 330 gallon tank on a trailer and hauled for reuse as test water 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: V- QV Date: 12/1312011.