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SWR CB,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 farm, 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 /> Facility Name:7-ELEVEN#32190,MKT 2368 Date of Testing:5/25/2012 <br /> Facility Address:4943 S.KINGSLEY(FRONTAGE RD) HWY 99 @ ARCH AIRPORT RD,STOCKTON,CA 95206 <br /> Facility Contact:MGR-LORENA Phone: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: Steven Willems <br /> Credentials: r CSLB Licensed Contractor r SWRCB Licensed Tank Tester <br /> License Type: il.icense Number: <br /> Manufacturer Training <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 /> TestedMade Tested Made <br /> Spill Box T4 regular fill X <br /> Spill Box T5 mul fill X <br /> Spill Box T6 supreme fill 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 TMS TESTING <br /> To the best of my knowleddgggee,, the facts stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: ,J'—0&%,� Date: 5/25/2012 <br />