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SWRCB January 2002 RECEIVED <br /> Secondary Containment Testing Report Form NOV 2 4 2014 <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 procedfiNVfR@"M ', tstA9ALTH <br /> applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. DEPARTMENT <br /> 1. FACILITY INFORMATION <br /> Facility Name:7-ELEVEN#19976,MKT 2368 jDate of Testing:10/13/2014 <br /> Facility Address: 1399 N.MAIN ST. @ NORTHGATE,MANTECA,CA 95336 <br /> FPhone:209-239-3252 <br /> Facility Contact:BEN <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(if present during testing):unknmn <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name:TANKNOLOGY INC. <br /> Technician Conducting Test:Jarrod Cooke <br /> Credentials: r CSLB Licensed Contractor r SWRC13 Licensed Tank Tester <br /> License Type:a License Number:743160 <br /> Manufacturer Training <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 /> Spill Box T5 pul fill X X <br /> Spill Box T4 rul fill X X <br /> Spill Box T5 pul fill X <br /> Spill Box T4 rul fill X <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> taken/recycled water trailer <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING TfUS TESTING <br /> To the best of my knowledge, <br /> tthe�fac_ts stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: ' '' Date: 10/13/2014 <br /> WO:2319460 <br />