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SWRCB,January 2002 Page 1 of I <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 for 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 /> FacilityName:7-ELEVEN#14117,MKT 2368 1 Date of Testing:2/17/2012 <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: <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: r CSLB Licensed Contractor r SWRCB Licensed Tank Tester <br /> License Type: License Number: <br /> Manufacturer Trainina <br /> Manufacturer Component(s) Date Training Expires <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> Spill Box T1 UNLEADED F X <br /> Spill Box 2 PREMIUM F X <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 knowledgethe facts stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: �/ — '� Date: 2/17/2012 <br />