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SWRCB, January 2002 <br />Page 1. <br />Secondary Containment Testing Report Form <br />This• form is intended for use by contractors perfbrrning periodic testing of UST sec•ondury c•ontuinnrent stistems. Use the <br />appropriate pages of this form to report results fere 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 suh. mittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: 7 -ELEVEN # 19976 MKT <br />2237 <br />DateofTesting: 02/14/2006 <br />Facility Address: 1399 N. MAIN ST. , <br />MANTECA, CA, 95336 <br />Facility Contact: BEN <br />Phone: (2 0 9) 2 3 9- 3 2 52 <br />Date Local Agency Was Notified of Testing <br />CSLB Licensed Contractor SWRCB Licensed Tank Tester <br />Name of Local Agency Inspector (if present during testing): <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: TANKNOLOGY, INC. <br />Technician Conducting Test: <br />ANEIL CHAND <br />Component <br />Credentials: <br />CSLB Licensed Contractor SWRCB Licensed Tank Tester <br />. :.. . - <br />0000 <br />License Type: <br />License Number: <br />a000 <br />Manufacturer <br />Manufacturer Training <br />Component(s) <br />Date Training Expires <br />Spill:.. <br />0000 <br />0000 <br />0000 <br />3. SUMMARY OF TEST RESULTS <br />If hvdrostatic 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 of my knowledge, the facts stated in this document are accurate and in full compliance with legal requirements <br />Technician's Signature: - Date: 02/14/2006 <br />Component <br />. :.. . - <br />0000 <br />a000 <br />Spill:.. <br />0000 <br />0000 <br />0000 <br />0000 <br />�■0000 <br />a000� <br />0000 <br />a000 <br />0000 <br />0000 <br />0000 <br />0000 <br />a000 <br />0000 <br />0000 <br />0000 <br />0000 <br />0000 <br />0000 <br />0000 <br />0000 <br />0000 <br />If hvdrostatic 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 of my knowledge, the facts stated in this document are accurate and in full compliance with legal requirements <br />Technician's Signature: - Date: 02/14/2006 <br />