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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 farm, 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 /> 1. FACILITY INFORMATION <br /> FacilityName: 7-ELEVEN #14117, MKT 2368 DateofTesting: 03/09/2010 <br /> Facility Address: 2725 COUNTRY CLUB BLVD STOCKTON, CA, 95204 <br /> Facility Contact: MANAGER - GIL Phone: (2 0 9) 4 63-1259 <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(if present during testing): RAY VON FLUE <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TANKNOLOGY, INC. <br /> Technician Conducting Test: KRISTOPHER BELL <br /> Credentials: El CSLB Licensed Contractor F-1 SWRCB Licensed Tank Tester <br /> License Type: CONTRACTOR I License Number: 743160 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> OPW INSTALATION 09/01/2011 <br /> r / <br /> r / <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Repairs Not Repair <br /> Component Pass Fail Tested Made Component Pass Fail Tested Made <br /> Spill Box 1 PRE FILL ❑ ❑ ❑ 1:1 El El El <br /> Spill Box 2 REG FILL X ❑ ❑ ❑ ❑ D 1-1 171 <br /> El El El <br /> tl El El El El El El <br /> El- <br /> El F-1 ❑ 11 El El El <br /> El- <br /> El ❑ 0 1 ❑ 1 ❑ ❑ ❑ ❑ <br /> D El El El El El El El <br /> E E El El El E E- <br /> EEl ❑ ❑ 1:1 El ❑ ❑ <br /> D El E El El El Ll <br /> El El Ll D Ll 1-1 Ll Ll <br /> ❑ 1 0 L1 ❑ ❑ 0 ❑ L-1 <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> LEFT WATER IN DRUM THAT WAS ON SITE <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: --I--- Date: 03/09/2010 <br />