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SWRCB,January 2002 0 Page 1. <br /> Secandy 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 ownerfoperator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: 7-ELEVEN #32190 (N-3810) , MKT 2237 Date of Testing: 41/08/2008 <br /> Facility Address: 4943 S. KINGSLEY (FRONTAGE RD) HWY 99 @ ARCH AIRPORT RD, STOCKTON, CA, <br /> Facility Contact: MGR - LORENA Phone: (2 0 9) 93 9-0 679 <br /> Date Local Agency Was Notified of Testing <br /> Name of Local Agency Inspector(if present during testing): GARRET REHS <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TANKNOLOGY, INC. <br /> Technician Conducting Test: JOEY MESA <br /> Credentials: ❑ CSLB Licensed Contractor SWRCB Licensed Tank Tester <br /> License Type: ICC SERVICE TECH, License Number: 5259458-UT <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> OPW SPILL BUCKET 12/17/2007 <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 El 1:1 0 E D 1-1 El <br /> Spill Box 4 REG FILL E ❑ ❑ E] El 0 El E <br /> Spill Box 5 MID FILL X ❑ D El El 0 <br /> LJJ��JJJ <br /> F-11 ❑ El El <br /> El ❑ D El <br /> El E <br /> El El F:1 El <br /> E E] El D El El <br /> El El El El 1-1 Ll El <br /> E E E ❑ <br /> E-1 F1E E <br /> [71E El <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> LEFT IN WASTE DRUM ON SITE. <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: 111"` Date: 01/08/2008 <br />