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SWRCB, January 2002 <br />Page <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 ofthis 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 ownerloperatorfor submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: 7 -ELEVEN #32262, MKT 2368 (N-3940-1 ---T —DateofTesting: 05/12/2010 <br />Facility Address: 2360 W GRANTLINE 1-205 OFF RAMP, TRACY, CA, 95376 <br />Facility Contact: CHANDRA —TPhone: (209) 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 />"IComponent <br />IffM:: <br />Credentials: <br />CSLB Licensed Contractor ❑ SWRCB Licensed Tank Tester <br />License Type: ICC <br />Manufacturer <br />License Number: 8001435 <br />Manufacturer Training <br />Component(s) <br />Date Training Expires <br />OPW <br />SPILL BUCKETS <br />09/01/2011 <br />,Spill Box 5 MID FILL <br />3. SUMMARY OF TEST RESULTS <br />ComponenL , tM <br />17-1 -1 <br />"IComponent <br />IffM:: <br />!Spi 1 Box 4 REG FILL <br />,Spill Box 5 MID FILL <br />Spill Box 6 PRE FILL <br />FE I <br />"M <br />WATER WAS PUT IN,WASTE DRUM ONSITE <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my knowledge, thefacts stated in this document are accurate and in full compliance with legal requirements <br />.4 <br />Technician's Signature: Date: 05/12/2010 <br />