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KLUEIVED <br /> SWRCB,January 2002 0 C T 24 20 1Ige 1 of 1 <br /> Secondary Containment Testing Report Form ENVIRONMENT <br /> This form is intended for use by contractors performing periodic testing of UST secondary containment sysklmdrN de 4 <br /> pages of this form to report results for all components tested. The completedform, written testprocedures,and printouts from tests(ij <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#17334 MKT 2368(N-747) Date of'I'esting: 10/11/2013 <br /> Facility Address:4501 N.PERSRING AVE. @ ROSEMARIE LN.,STOCKTON,CA 95207 <br /> Facility Contact:MGR-SATBIR Phone:209-951-6745 <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(if present during testing):garret <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name:TANKNOLOGY INC. <br /> Technician Conducting Test:Jarrod Cooke <br /> Credentials: r CSLB Licensed Contractor r SWRCB Licensed Tank Tester <br /> License Type:a ILicense Number:743160 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> tanknology all 5/162014 <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> Spill Box T-1.1 fill X <br /> Spill Box T-2 put fill X <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> taken/recycled water trailer <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING TIIIS TESTING <br /> To the best of my knowledge,the facts stated in this document are accurate and in full compliance with legal requirements <br /> Techniciads Signature: � Date: 10/11/2013 <br /> WO:2313415 <br />