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SWRCB,January 2002 Now., *"O 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 #17334 MKT 2368 7 DateofTesting: 10/10/2011 <br /> Facility Address: 4501 N. PERSHING AVE. @ ROSEMARIE LN. , STOCKTON, CA, 95207 <br /> Facility Contact: SATBIR - PERMIT: (N-747-1-6) Phone: (209) 951-6745 <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: ❑X CSLB Licensed Contractor SWRCB Licensed Tank Tester <br /> License Type: ICC SERVICE TECH. I License Number: 5259458—UT <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> OPW SPILL BUCKET 11/14/2011 <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Repairs Not Repair <br /> Component Pass Fail Tested Made Component Pass Fail Tested <br /> Spill Box 1 UNL FILL El El El � � 0 <br /> Spill Box 2 PRE FILL El El ❑ � El ❑ El <br /> El- <br /> 0 El Q Q El El 0Ej <br /> Ej El � El El <br /> PEE] <br /> El El ED 01 � ElEj <br /> El El Ej <br /> El 0 El � � 0 <br /> El El El El El 0 <br /> El El <br /> El El El El El El <br /> El El ED El El Ej <br /> 0101 El I El I Ell Ell El aj <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> TOOK WITH AS TEST WATER. <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: 10/10/2011 <br />