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• . <br /> SV4'RCB,January 2002 Page 1 <br /> Secondary Containment Testing Report Form <br /> This form is intended for use by contractors performingperiodic 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 (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 414117, MKT 2368 <br /> Date of Testing: 05/19/2008 <br /> Facility Address: 2725 COUNTRY CLUB BLVD STOCKTON, CA, 95204 <br /> Facility Contact: MANAGER - G IL Phone: (2 0 9) 463-1259 <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(if present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TANKNOLOGY, INC. <br /> Technician Conducting Test: ,JARROD COOKE <br /> Credentials: ❑ CSLB Licensed Contractor SWRCB Licensed Tank Tester <br /> License Type: License Number: <br /> Manufacturer Trainin Date Training Expires <br /> Manufacturer Component(s) <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Repairs Not Repair <br /> Component Pass Fail Tested Made <br /> Component Pass Fail Tested <br /> Made- <br /> Spill Box 1 PRE FILL l X 0 E] El 0 EJ <br /> r� ❑ 0o 000nE <br /> Ij El El LJ <br /> EJ- <br /> El ElEl El El 0- <br /> El <br /> D a El 0 L� <br /> El0 ❑ ❑ a <br /> 01:10 El 0 0 <br /> ❑ ❑ ❑ a Q 0 ❑ <br /> Ell Ell El <br /> EE E <br /> El El <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <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 /> Technicians Signature: <br /> J� Date: 05/19/2008 <br />