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SWRCB,January 2002 *M10 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 /> FacilityName: 7-ELEVEN #17334 MKT 2368 (N-747) DateofTesting: 10/12/2010 <br /> Facility Address: 4501 N. PERSHING AVE. @ ROSEMARIE IN. , STOCKTON, CA, 95207 <br /> Facility Contact: MGR - SATBIR Phone: (209) 951-6745 <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(if present during testing): GARRETT <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TANKNOLOGY, INC. <br /> Technician Conducting Test: JON ADAMS <br /> Credentials: CSLB Licensed Contractor SWRCB Licensed Tank Tester <br /> License Type: A I License Number: 743160 <br /> Manufacturer Trainine <br /> Manufacturer Component(s) Date Training Expires <br /> DPW SPILL BUCKETS 11/04/2011 <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 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Spill Box 2 PRE FILL ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ El El ❑ ❑ ❑ ❑ <br /> El El ❑ ❑ El El ❑ ❑ <br /> ❑ ❑ ❑ ❑ El El ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ El EJ ❑ El- <br /> El El ❑ ❑ ❑ ❑ -1 ❑ <br /> 1:1 El 1:1 El ❑ ❑ ❑ ❑ <br /> El El I ❑ I ❑ I El Eli ❑ ❑ <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 ofmy knowledge, the facts stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: A,— 5 Date: 10/12/2010 <br />