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Page 1. <br /> SWRCB,January 2002 <br /> Secondipy Containment Testing Rep t 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 fhould be p o ided tompe faC lity o nerThe <br /> eratorl orsubmittal towritten <br /> the locpalp egulatory agency. <br /> and <br /> printouts from tests (af applicable), p h f ty P .f <br /> 1. FACILITY INFORMATION <br /> Facility Name: 7--ELEVEN #14117, MKT 2366 DateofTesting: 04/02/2009 <br /> Facility Address: 2725 COUNTRY CLUB BLVD STOCKTON, CA, 95204 <br /> Facility Contact: MANAGER - G I L Phone: (2 0 9) 463-1259 <br /> Date Local Agency Was Notified of Testing : / / <br /> Name of Local Agency Inspector(if present during testing): RAY VON FLUE REHS <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TANKNOLOGY, INC. <br /> Technician Conducting Test: JOEY MESA <br /> Credentials: CSLB Licensed Contractor 0 SWRCB Licensed Tank Tester <br /> License Type: ICC SERVICE TECH. I License Number: 5259458-UT <br /> ManufacturerTraining <br /> Manufacturer Component(s) Date Training Expires <br /> Opp SPILL BUCKET 12/18/2010 <br /> r / <br /> r / <br /> r r <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Repairs Component Pass Fail Not Repair <br /> Com Made <br /> Component Pass Fail Tested Made p Tested <br /> Spill Box 1 PRE FILL X❑ <br /> Spill Box 2 REG FILL <br /> U <br /> ❑ 0 0 El El 0 EI- <br /> 0 <br /> 0 0 0 0 ❑ 0 0 0 <br /> 1 ❑ El El D <br /> 11-a El El El EL <br /> O 0 0 0 ❑ 0 0 ❑ <br /> 0 0 0 0 0 <br /> 0 ❑ 0 0 0EL <br /> ❑ ❑ 0 ❑ ❑ ❑ 0 0 <br /> If hydrostatic testing was performed,describe what was done with the water ager completion of tests: <br /> LEFT ONSITE. <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: <br /> 1 .� Date: 04/02/2009 <br />