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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 /> 1. FACILITY INFORMATION <br /> Facility Name: 7-ELEVEN #32190, MKT 2368 Dateof Testing: 02/08/2010 <br /> Facility Address: 4943 S. KINGSLEY (FRONTAGE RD) HWY 99 Q ARCH AIRPORT RD, STOCKTON, CA, <br /> Facility Contact: MGR - LORENA Phone: (209) 939-0679 <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 El SWRCB Licensed Tank Tester <br /> License Type: a I License Number: 743160 <br /> Manufacturer Trainine <br /> Manufacturer Component(s) Date Training Expires <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Repairs Not Repair <br /> Component Pass Fail Tested Made Component Pass Fail Tested Made <br /> Secondary Pipe 5 MID PLUS El El 0 E E El 11 El <br /> Q Q El F-1 El E Ej El <br /> 0 E E 1:1 F-1 1:1 E El <br /> Ell E 1:1 ElE] <br /> El E <br /> El EJ E <br /> E Ell E <br /> El El El El El El El <br /> Q El El Q 1:1 El El <br /> El E El El El 1-1 <br /> ❑ ❑ ❑ ❑ ❑ ❑ Q I ❑ <br /> L1 El El El E El F-1 L1 <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, thefacts stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: w^r'^`— Date: 02/08/2010 <br />