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SWRCB, January 2002 , 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 />Facility Name: 7 -ELEVEN #32262, MKT 2368 (N-3940-1 <br />Date of Testing: 05/12/2010 <br />Facility Address: 2360 W GRANTLINE I-205 OFF RAMP, TRACY, CA, 95376 <br />Facility Contact: CHANDRA <br />Phone: (2 0 9) 830-9917 <br />Date Local Agency Was Notified of Testing <br />Name of Local Agency Inspector (if present during testing): STACY RIVERA <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: TANKNOLOGY , INC. <br />Technician Conducting Test: <br />TIMOTHY ELEBECK <br />Credentials: <br />CSLB Licensed Contractor <br />SWRCB Licensed Tank Tester <br />� Box - - ■0000 <br />License Type: ICC <br />Manufacturer <br />I License Number: 8001435 <br />Manufacturer Training <br />Component(s) <br />Date Training Expires <br />OPW <br />SPILL BUCKETS <br />09/01/2011 <br />. :. MID FILL <br />k111121 1 ! 1u 1.1111 K-1]011Y�4lid <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />WATER WAS PUT IN WASTE DRUM ONSITE <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: EAJ.� Date: 05/12/2010 <br />� Box - - ■0000 <br />0000 <br />. :. MID FILL <br />0000 <br />Spill:.... <br />0000 <br />0000 <br />0000 <br />0000 <br />0000 <br />0000 <br />0000 <br />0000 <br />0000 <br />0000. <br />� <br />0000 <br />0000.: <br />■ �0000�■ <br />0000.: <br />■■■0000 <br />0000:: <br />0000 <br />0000 <br />0000 <br />0000� <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />WATER WAS PUT IN WASTE DRUM ONSITE <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: EAJ.� Date: 05/12/2010 <br />