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SWRCB, January 2002 Page 1 of 1 <br />Secondary Containment Testing Report Form 6 r 12 5 20 13 <br />This form is intended for use by contractors performing periodic testing of UST secondary containment�tems. Use the appropriate <br />pages of this form to report results for all components tested. The completed form, written test proce, and printouts from tests (if <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 # 19976, MKT 2368 jDate of Testing: 10/22/2013 <br />Facility Address: 1399N. MAIN ST. @ NORTHGATE, MANTECA, CA 95336 <br />Facility Contact: BEN Phone: 209-239-3252 <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 />Pass <br />fechnician Conducting Test: Garrett Warren <br />Not <br />Tested <br />Credentials: rv— CSLB Licensed Contractor <br />r— SWRC13 Licensed Tank Tester <br />License Type: A <br />License Number: 743160 <br />Manufacturer <br />Manufacturer Training <br />Component(s) Date Training Expires <br />OPW <br />Spill bucket 2/26/2015 <br />3. SUMMARY OF TEST RESULTS <br />Component <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />Component <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />Spill Box T4 rul fill <br />X <br />Spill Box T5 pul fill <br />X <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />CERTIFICATION OF TECBMCIAN RESPONSIBLE FOR CONDUCTING UHS 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: rt Date: 10/22/2013 <br />WO: 2313418 <br />