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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 /> FacilityName: 7-ELEVEN #32190, MKT 2368 Dateof Testing: 06/21/2010 <br /> Facility Address: 4943 S. KINGSLEY (FRONTAGE RD) HWY 99 @ 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): THUY IRAN <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TANKNOLOGY, INC. <br /> Technician Conducting Test: MICHAEL STRANGE <br /> Credentials: CSLB Licensed Contractor SWRCB Licensed Tank Tester <br /> License Type: License Number: <br /> Manufacturer Trainine <br /> Manufacturer Component(s) Date Training Expires <br /> ICC SERVICE TECH 8028170-UT 04/18/2011 <br /> OPW INSTALLER 5190 09/01/2011 <br /> CA CSL 743160 <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not <br /> Tested Made P Repair <br /> Tested Made <br /> Spill BOX 4 REG FILL El ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Spill Box 5 MID FILL ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Spill Box 6 PRE FILL ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> El ElI El1:1 El 10 <br /> El El El El E] El El <br /> El I El El El El El Q El <br /> El 0 El El 1:1 El <br /> 0 El 0 El Q E <br /> El El El I Ell El I <br /> El El E] El El El <br /> El Q El El El El EEEll El I El Ej El � El <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> FM 186.2 FOR TRUCK TRANSPORT <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best ofmy knowledge, the facts stated in <br /> this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: \� �" Date: 06/21/2010 <br />