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1 t <br /> SWRCB,January 2002 Page I of 1 <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 appropriate <br /> pages of this form to report results far all components tested. The completed form, written test procedures, and printouts from tests <br /> (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name:7-ELEVEN#14117,MKT 2368 Date of Testing: 11/19/2012 <br /> Facility Address:2725 COUNTRY CLUB BLVD ,STOCKTON,CA 95204 <br /> Facility Contact:MANAGER-GIL Phone:463-1259 <br /> Date Local Agency Was Notified of Testing:I 1/12/2012 <br /> Name of Local Agency Inspector(if present during testing): not present <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name:TANKNOLOGY INC. <br /> Technician Conducting Test:Jarrod Cooke <br /> Credentials: r CSLB Licensed Contractor r—SWRCB Licensed Tank Tester <br /> License Type: a ILicense Number:743160 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> tanknology all 5/162014 <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Not Repairs <br /> Component Pass Fail T stedRM des Component Pass Fail Tested Made <br /> Tank Annular*2 X <br /> Tank Annular*1 A' <br /> Secondary Pipe Test(Tank I-put) X <br /> Secondary Pipe Test(Tank 2-mp X <br /> STP Containment for Tank 1 put-I X <br /> STP Containment for Tank 2 rul-1 X <br /> UDC N 1/2 X <br /> If hydrostatic testing was performed,describe what was done with the water atter completion of tests:taken water trailer <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,the facts stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: Date: 11/192012 <br /> WO:2306814 <br />