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SWRCB,January 2002 Page 1 of I <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 appropriate <br /> pages of this form to report results for all components tested. The completed form,written test procedures, and printouts from tests(f <br /> 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(N-747) jDate of Testing: 12/1/2015 <br /> Facility Address:4501 N.PERSfENG AVE. @ROSEMARIE LN.,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):unknown <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name:TANKNOLOGY INC. <br /> Technician Conducting Test:Jarrod Cooke <br /> Credentials: r CSLB Licensed Contractor r SWRCB Licensed Tank Tester <br /> License Type:a ILicense Number:743160 <br /> Manufacturer Trainine <br /> Manufacturer Component(s) Date Training Expires <br /> tanknology all 5/16/2016 <br /> 3.SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> Tank Annular#T-1 X <br /> Tank Anular#TQ x <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> na <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCT'IN'G THIS TESTING <br /> To the best of my knowledge,,�tt--heef�facts stated In this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: e/' � Date: 12/1/2015 <br /> WO:23257887 <br />