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SWRCB,January 2002 Page 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 <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 /> L FACILITY INFORMATION <br /> Facility Name: 7-ELEVEN #14117, MKT 2368 1 DateofTesting: 04/18/2008 <br /> Facility Address: 2725 COUNTRY CLLR BLVD STOCKTON, CA, 95204 <br /> Facility Contact: MANAGER - GI 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): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TANKNOLOGY, INC. <br /> Technician Conducting Test: RHOME DESBIENS <br /> Credentials: CSLB Licensed Contractor SWRCB Licensed Tank Tester <br /> License Type: License Number: <br /> Manufacturer Trainin <br /> Manufacturer Component(s) <br /> Date Training Expires <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Repairs Pass Fail Not Repair <br /> Component Pass Fail Tested Made Component Tested Made <br /> Spill Box 2 REG FILL 0 0 0 0 El 0 <br /> Spill Box 1 PRE FILL ❑ X❑ 0 El 0 � D E <br /> 0 E0 0 1:1 1:10 0 <br /> 0 0 0 0- D_ El- <br /> E] El <br /> 00 0 EL 00 0 <br /> EJ El El 1:1 E <br /> 00 EL 00 0 ❑ <br /> 0 0 0 ElEl El <br /> 0 0 0 U El El <br /> ❑ ❑ 00 a00 0 0 <br /> 00 0 1:1 EL <br /> 0 0 ❑ D 0 <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 /> 04/18/2008 <br /> Technician's Signature: a�� <br /> Date: <br />