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SWRCB,January 2002 Page I of 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 appropriate <br /> pages of this form to report results for all components tested. The completed form, written test procedures, and printouts from tests <br /> (if 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#14117,MKT 2368 Dale of Testing:2/20/2013 <br /> Facility Address:2725 COUNTRY CLUB BLVD ,STOCKTON,CA 95204 <br /> Facility Contact:MANAGER-GIL Phone:463-1259 <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:TAINC. <br /> Technician Conducting Test:Timothy Elebeck <br /> Credentials: �CSLB Licensed Contractor FSWRCB Licensed'rank Tester <br /> License Type: License Number: <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> opw sb 9/15/2013 <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Repairs Not Repairs <br /> Component Pass Fail Teste Made Component Pass Fail Tested Made <br /> Spill Box TI put fill X <br /> Spill Box T-2 ml fill X <br /> PEE i <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests:water was taken as test water <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: `�.w..�rJx.y F'�'4Date: 2/20/2013 <br /> WO:2309058 <br />