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SWRCB,January 2002 Page 1 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(if <br /> 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,MKT 2368 jDate of Testing:5/23/2013 <br /> Facility Address:4943 S.KINGSLEY(FRONTAGE RD) HWY 99 @ ARCH AIRPOItT RD,STOCKTON,CA 95206 <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): 11 <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name:TANKNOLOGY INC. <br /> Technician Conducting Test:Jason Castillo <br /> Credentials: r CSLB Licensed Contractor SWRCB Licensed Tank Tester <br /> License Type:A License Number:743160 <br /> Manufacturer Trainin <br /> Manufacturer Component(s) Date Training Expires <br /> OPW Spill Bucket 2/26/2015 <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Repairs Not Repairs <br /> Component Pass Fail Tested Made Component Pass Fail Tested Made <br /> Spill Box T4 rul fill X <br /> Spill Box T5 mul fill X <br /> Spill Box T6 pul 611 K <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,th/elfacts stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: <br /> 'r <br /> Date: 5/2312013 <br /> WO:2310970 <br />