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SWRC%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 of this form to report results for all components tested. The completed form, 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 /> FacilityName: CIRCLE K 2701205 Date of Testing: 10/14/2010 <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): THUY TRAN <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TANKNOLOGY, INC. <br /> Technician Conducting Test: KELVIN CRUZ <br /> Credentials: E CSLB Licensed Contractor ❑ SWRCB Licensed Tank Tester <br /> License Type: CONTRACTOR License Number: 743160 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> OPW PHASEI 11/04/2011 <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 1:1 El D El <br /> Spill Box 2 SUP FILL ❑ ❑ E <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ El- <br /> El <br /> ❑ ❑ ❑ ❑ Q 1 ❑ ❑ ❑ <br /> El I El El El El <br /> El El � E El <br /> ❑ ❑ ❑ ❑ ❑ <br /> El El � El Q El I <br /> � E E <br /> EI El El El <br /> El Eli El ED El El El <br /> El 01 Ej Ej Fj F-1 F-1 Ej <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> TOOK AS TEST WATER. <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: �E Date: 10/14/2010 <br />