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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 (N-3810) , MKT 2368 DateofTesting: 12/15/2008 <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): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TANKNOLOGY, INC. <br /> Technician Conducting Test: STEVEN WILLEMS <br /> Credentials: CSLB Licensed Contractor SWRCB Licensed Tank Tester <br /> License Type: I License Number: <br /> Manufacturer Training <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 /> Spill Box 3 PRE FILL E ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Spill Box 4 REG FILL Lfl ❑ ❑ ❑ ❑ ❑ ❑ <br /> Spill Box 5 MID FILL Q El ❑ El ❑ ❑ ❑ <br /> Ell D El E <br /> El El Q El E <br /> Q 1 El El El El <br /> ❑ ❑ 1 ❑ I ❑ ❑ <br /> El El El El El El <br /> ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ I ❑ ❑ ❑ <br /> E El El El � El <br /> ElElEl El ❑ ❑ ❑ 01 <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 <br /> ninnthis document are accurate and in full compliance with legal requirements <br /> Technician's Signature: Date: 12/15/2008 <br />