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0 <br />p ec <br />Page 1 of 8 ECO CH KCOWLIKMCL <br />Secondary Containment Testing Report Form <br />This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the <br />appropriate pages of this form to report results for all components tested The completed form, written test procedures, and <br />printouts from tests (tf applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: Fast and Easy 960 L Date of Testing: 10/24/2011 <br />Facility Address: 10878 N Highway 99 Frontage Road, Stockton, CA 95212 <br />Facility Contact: Mike Ali Phone: (707) 747-2958 <br />Date Local Agency Was Notified of Testing: 10/14/2011 <br />Name of Local Agency Inspector (if present during testing): <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: ECO-CHEK Compliance <br />Technician Conducting Test: Nik Zagorov <br />Credentials: ® CSLB Licensed Contractor <br />® SWRCB Licensed Tank Tester <br />License Type: A License Number: 958763 <br />Manufacturer Train ine <br />Manufacturer Component(s)) Date Training Expires <br />Caldwell lnstruments, Inc. <br />Level Change Indicator NIA <br />- Space00� <br />�� <br />m■ <br />E <br />■0 <br />3. SUMMARY OF TEST RESULTS <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />Placed in a 330 gallon tank on a trailer and hauled for reuse as test water <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my knowledge, thefacts stated in this document are accurate and in full compliance with legal requirements <br />Technician's Signature: Y"OV bate: 10/24/2011 <br />mm� <br />- Space00� <br />�� <br />m■ <br />E <br />■0 <br />■On0■ <br />- . •$-. . <br />►, <br />nno <br />mm00 <br />Secondary .. <br />►: <br />nno <br />nnoo <br />K <br />®ono <br />nnoo <br />ooni0 <br />nnn© <br />nnno <br />nano <br />nnn� <br />nnno <br />n <br />■ <br />n� <br />_ <br />- nnoo. <br />nnr <br />■o <br />nnoo <br />nnoo <br />nnoo <br />nnoo <br />nnoo <br />veno <br />oono <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />Placed in a 330 gallon tank on a trailer and hauled for reuse as test water <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my knowledge, thefacts stated in this document are accurate and in full compliance with legal requirements <br />Technician's Signature: Y"OV bate: 10/24/2011 <br />