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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 ofthis form to report results for all components tested. The completedform, written testprocedures, and <br /> printouts from tests(3fapplicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> FacilityName: 7-ELEVEN #32190, MKT 2368 1 Dateof Testing: 06/07/2011 <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): Michelle H <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TANKNOLOGY, INC. <br /> Technician Conducting Test: STEVEN WILLEMS <br /> Credentials: 1fl CSLB Licensed Contractor ❑ SWRCB Licensed Tank Tester <br /> License Type: icc License Number: 8016974 <br /> Manufacturer Trainine <br /> Manufacturer Component(s) Date Training Expires <br /> opw spill bucket 10/02/2012 <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Repairs Not Repair <br /> Component Pass Fail Tested Made Component Pass Fail Tested <br /> Made <br /> Spill Box 4 REG FILL ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Spill Box 5 MID FILL E ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Spill Box 6 PRE FILL E ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Ej 1:1 El Q <br /> F] El EM] <br /> D El <br /> El 01 El El 0 <br /> El El El El <br /> E E El El El <br /> D El <br /> El 11:111:1 D <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> put in buckets with lids and take with me <br /> CERTIFICATION OF TECHNICIAN RESPONSHiLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge, thefacts statedin <br /> tthis document are accurate and in full compliance with legal requirements <br /> Technician's Signature: �(y,,., 11�JtXlLvN. Date: 06/07/2011 <br />