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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(�f applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> I. FACILITY INFORMATION <br /> Facility Name: CIRCLE K 2701205, CO. 123 (N-206) Dateof Testing: 05/02/2008 <br /> Facility Address: 16470 CAMBRIDGE , LATHROP, CA, 95330 <br /> Facility Contact: MANAGER-ROBERT Phone: (209) 858-4116 <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: HEATH MCEVER <br /> Credentials: ❑ CSLB Licensed Contractor SWRCB Licensed Tank Tester <br /> License Type: SERVICE TECH License Number: 5236756-UT <br /> Manufacturer Trainin¢ <br /> Manufacturer Component(s) Date Training Expires <br /> OPW SPILL BUCKET 06/13/2008 <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 1 UNL FILL ❑ El ❑ ❑ ❑ ❑ ❑ ❑ <br /> Spill Box 2 SUP FILL ff] ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ I ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> V ❑ ❑ ❑ ❑❑ ❑ ❑ ❑❑ ❑ ❑NO] <br /> ❑❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑❑ ❑❑ °❑ <br /> ❑ ❑ ❑ ❑ El El ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> TRANSPORTED AS TEST FLUID <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: /® Date: 05/02/20-08 <br />