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! 6 00 <br /> SWRCS,January 2402 RECEIVED <br /> Secondary Containment Testing Report Form <br /> This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Mydp Nate <br /> Pages of this form to report results for all components tested. The completed form, written test procedure�jr 9m tests(ifapplicable), should be provided to the facility owner/operator for submittal to the local regulatory age V� MIE111V1TAL <br /> I. FACILITY INFORMATION HEALTH DEPARTMENT <br /> Facility Name:7-ELEVEN#32190,MKT 2368 jDate of Testing:5/13/2014 <br /> Facility Address:4943 S.KINGSLEY(FRONTAGE RD) HWY 99 @a ARCH AIRPORT RD,STOCKTON,CA 95206 <br /> Facility Contact:MGR-LORENA Phone:249-939-0679 <br /> Date Local Agency Was Notified of Testing: <br /> Nance of Local Agency Inspector(if present during testing): <br /> 2, TESTING_ CONTRACTOR INFORMATION <br /> Company Name:TANKNOLOGY INC. <br /> "technician Conducting Test:Gilbert Garcia <br /> Credentials: W CSLB Licensed Contractor r— SWRCS Licensed Tank Tester <br /> License Type: -Number:743160 <br /> Manufacturer Training <br /> =Manufacturer Component(s)� Date Training Expires <br /> OPW SPILL BUCKET 2/4/2015 <br /> OPW SPILL BUCKET 2/4/2415 <br /> OPW SPILL BUCKET 2/4/2015 <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass FailNot Repairs Not Repairsil <br /> Tested Made Component Pass Fail <br /> Tested Made <br /> Spill Box T4 rul fill X <br /> Spill Box T5 mul fill X <br /> Spill Box Tb put fill X <br /> If hydrostatic testing was performed,describe what was done with the water aller coniplelion of tests: <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: 5/13/2014 <br /> WO:2317293 <br />