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SWRCB,Jan �./ <br /> nary 2ooz <br /> Page 1 of 1 <br /> Secondary Containment Testing Report Forme C�'►jlr <br /> This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the appropriate <br /> EID <br /> pages of this form to report results for all components tested. The completed form,written test procedures, and printouts frnmUU-tesJ (yj 3 2015 <br /> applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. CCI. rZ� <br /> 1. FACILITY INFORMATION LiNiviemENTAL <br /> Facility-Name:7-ELEVEN#17334 MKT 2368(N-747) llate of Testing: 12/1/2015 -�a!-runaw TeAcP'!T <br /> Facility Address:4501 N.PERSHING 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):unknown <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name:TANKNOLOGY INC. <br /> Technician Conducting Test:Jarrod Cooke <br /> Credentials: r CSLB Licensed Contractor r S WRCB Licensed Tank Tester <br /> License Type:a License Number:743160 <br /> Manufacturer Trainine <br /> Manufacturer Component(s) Date Training Expires <br /> tanknology all 5/162016 <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> Tank Annular#T-1 X <br /> "I ank Amular#T-2 x <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> na <br /> CERTIFICATION OF TECFINICIAN RESPONSIBLE FOR CONDUCTING TILS TESTING <br /> To the best of my knowledge,,thefacts stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: 17"`Z� Date: 12/1/2015 <br /> WO:2325787 <br />