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SWRCB,January 2002 1...- Page 1. <br /> Secondary Containment Testing Repa'ft Form <br /> This form is intendedfor use by contractors performingperiodic testing of USTsecondary containment systems. Use the <br /> appropriatepages of this form to report results for all components tested. The completed form, written test procedures, and <br /> printouts from tests(3f applicable), should be provided to thefacility owner/operatorfor submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: CIRCLE K 2701205, CO. 123 (N-206) DateofTesting: 05/18/2007 <br /> Facility Address: 16470 CAMBRIDGE LATHROP, CA, 95330 <br /> Facility Contact: MANAGER Phone: (2 0 9) 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: JOEY MESA <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 /> 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 1:1 ❑ ❑ ❑ ❑ ❑ ❑ <br /> Spill Box 2 SUP FILL Efl ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Q El El El E El E <br /> EJ El Ej Ell E <br /> El E El El <br /> ❑ ❑ ❑ I I ❑ ❑ ❑ <br /> ❑ ❑ ❑ I ❑ ❑ ❑ <br /> El El El El El Ej El <br /> Ell ❑ ❑ Ell ❑ ❑ <br /> Ej I El E El El E <br /> El El El El El Ej <br /> El El El El El <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 in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: Date: 05/18/2007 <br />