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SWRCB,January 2002 Page I 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 completedform, written testprocedures, andprintouts from tests <br /> (if 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 417334 MKT 2368(N-747) Date of Testing:9/11/2012 <br /> Facility Address:4501 N.PERSHING AVE. @ ROSEMARIE LN.,STOCKTON,CA 95207 <br /> Facility Contact:MGR-SATBIR Phone:951-6745 <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(if present during testing):none <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 License Number:743160 <br /> Manufacturer Trainine <br /> Manufacturer Component(s) Date Training Expires <br /> tanknology all 5/16/2014 <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Repair Not Repairs <br /> Component Pass Fail TestedMade Component Pass Fail Tested Made <br /> Tank Annular#1 x <br /> Tank Annular#2 x <br /> (Tank 1-ml)STP Containment 1 to 3/4 x <br /> (Tank 2-pup STP Containment I to 3/4 x <br /> STP Containment for Tank 1 ml-1 x <br /> STP Containment for Tank 2 pul-1 x <br /> UDC#1/2 x <br /> UDC#3/4 x <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: taken water trailer <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THUS 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: 9/11/2012 <br /> WO:2304570 <br />