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SWRCB,January 2002 0 Page 1. <br /> Seconda* Containment Vesting Report Form <br /> This form is intended far 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 /> 1. FACILITY INFORMATION <br /> Facility Name: 7-ELEVEN #14117, MKT 2368 DateofTesting: 02/24/2011 <br /> Facility Address: 2725 COUNTRY CLUB BLVD , STOCKTON, CA, 95204 <br /> Facility Contact: MANAGER - GTL Phone: (2 0 9) 463-1259 <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(if present during testing): Stacy Rivera,ReHs <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TANKNOLOGY, INC. <br /> Technician Conducting Test: JULIAN TILLMAN <br /> Credentials: E CSLB Licensed Contractor SWRCB Licensed Tank Tester <br /> License Type: contractors I License Number: 743160 <br /> Manufacturer Trainine <br /> Manufacturer Component(s) Date Training Expires <br /> Phil Tite sb 01/03/2013 <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Repairs Not Repair <br /> Component Pass Fail Tested Made Component Pass Fail Tested Made <br /> Spill Box 1 PRE FILL 11�-11 ❑ ❑ I❑� 1-111 ❑ ❑ <br /> Spill Box 2 REG FILL x ❑ El <br /> I E:1 ❑ ❑ ❑ <br /> E D 0 0 El <br /> El El 71 El ❑ El El <br /> 171 171 F71 1:1 l E <br /> Er- <br /> El l nEl El El El El <br /> U E D 1:1 ❑ F-] El <br /> I Ell El ElI E M JI El <br /> E El 171 El <br /> El El El El El El El 1:1 <br /> E] 11 E] <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 /> Technician's Signature: ,/� z Date: 02/24/2011 <br />