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SWRCB,January 2002 %W1W *We Page 1. <br /> Secondary Containment Testing Report Form <br /> This form is intended for use by contractors performingperiodic testing of UST secondary containment systems. Use the <br /> appropriate pages of this form to report results for all components tested. The completed form,written test procedures,and <br /> pnntouts from tests(fapplicable),should be provided to the facility owner/operatorfor submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: CIRCLE K 2701205 Dateof Testing: 10/22/2009 <br /> Facility Address: 16470 CAMBRIDGE ® LOUISE, LATHROP, CA, 95330 <br /> Facility Contact: MANAGER-ROBERT Phone: (209) 858-4116 <br /> Date Local Agency Was Notified of Testing <br /> Name of Local Agency Inspector(if present during testing): MICHELLE <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TANKNOLOGY, INC. <br /> Technician Conducting Test: KRISTOPHER BELL <br /> Credentials: CSLB Licensed Contractor ❑ SWRCB Licensed Tank Tester <br /> License Type: I License Number: 52 9 77 93-ut <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> OPW INSTALATION <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Repairs Not Repair <br /> Component Pass Fail Tested Made Component Pass Fail Tested Made <br /> Spill Box 1 UNL FILL El ❑ ❑ ❑ ❑ ❑ ❑ D <br /> Spill Box 2 SUP FILL E ❑ ❑ ❑ 0 01 L1 El <br /> Ej El El Ej El 01 Q El <br /> El E] El El El Q L <br /> El I El EJ E] El El E <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> El D El E <br /> El El El E El ED <br /> Ej I Eli Ej 1 0 Ej 01 EEJI ED <br /> 011:111:1 1 1:1 <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> LEFT IN DRUM ONSITE <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: 10/22/2009 <br />