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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 thisform to report results for all components tested. The completed form, written test procedures, and <br /> printouts from tests(ifapplicable),should be provided to thefaciliry owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: 7-ELEVEN #32190(N-3810) , MKT 2366 DateofTesting: 12/01/2009 <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: BRYAN KEYS <br /> Credentials: E1CSLB Licensed Contractor 1fl SWRCB Licensed Tank Tester <br /> License Type: I License Number: 07-1735 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> OPW PHASE 1 01/08/2010 <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 4 REG FILL El ❑ 1:1 ❑ Q 1:1 Ej <br /> Spill Box 5 MID FILL E El ❑ El El El Q Q <br /> Spill Box 6 PRE FILL D E ❑ D El Q El <br /> El . EE11 Q 1:1 El El <br /> El Q El 01 El El El <br /> El El El El El E <br /> Q E Q E] El I <br /> El El El E] ED] El <br /> El Q El 01 El El E <br /> Q El r-1 El Ej El E <br /> El El Q El El <br /> El El El <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> TEST FLUID DRUMMED AND LEFT ON SITE <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: /may^ - le7�— Date: 12/01/2009 <br />