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SWRCB,January 2002 Page 1. <br /> Secondary Containment Testing Rept 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 completedform, written test procedures, and <br /> printouts from tests(f 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 #32190 (N-3810) , MKT 2368 1 DateofTesting: 12/30/2009 <br /> Facility Address: 4943 S. KINGSLEY (FRONTAGE RD) HWY 99 @ ARCH AIRPORT RD, STOCKTON, CA, <br /> Facility Contact: MGR - LORENA Phone: (209) 939-0679 <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(if present during testing): na <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TANKNOLOGY, INC. <br /> Technician Conducting Test: JARROD COOKE <br /> Credentials: F] CSLB Licensed Contractor ❑ SWRCB Licensed Tank Tester <br /> License Type: a License Number: 743160 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> tanknology all 07/18/2011 <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Repairs Not Repair <br /> Component Pass Fail Tested Made Component Pass Fail Tested Made <br /> Secondary Pipe 4 REG A El ❑ E ❑ UDC 5/6 D D ❑ <br /> Secondary Pipe 4 REG B E ❑ ❑ ❑ UDC 7/8 a ❑ ❑ ❑ <br /> Secondary Pipe 5 MID A 1:1 Ifl 1:1 1:1 UDC 9/10 <br /> Secondary Pipe 5 MID B X01 ❑ ❑ UDC 11/12 El 1:1 D <br /> Secondary Pipe 6 PRE A FLI ❑ <br /> Secondary Pipe 6 PRE B x ❑ ❑ ❑ O ❑ ❑ ❑ <br /> Piping Sump 4 REG X 1:1 ❑ <br /> Piping Sump 5 MID X El El El El El E1 ❑ <br /> Piping Sump 6 PRE El Q El El El El E <br /> Piping Sump 6 PRE X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> UDC 1/2 E ❑ ❑ ❑ ❑ ❑ ❑ <br /> UDC 3/4 IZI ❑ ❑ O ❑ El E <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> taken pump truck <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: 12/30/2009 <br />