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SWRCB,January 2002 <br /> Secondary Containment Testing Report Form RECEIVED) <br /> This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use t"ITropr�t�Q 14 <br /> pages of this form to report results for all components tested. The completed form,written test procedures,-. printouts from tests`19 <br /> applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> ENVIRONMENTAL HEALTH I <br /> 1. FACILITY INFORMATION <br /> Facility Name:7-ELEVEN 417334 MKT 2368(N-747) Date of Testing: 10/17/2014 <br /> Facility Address:4501 N.PERSHING AVE. @ROSEMARIE LN.,STOCKTON,CA 95207 <br /> Facility Contact:MGR-SATBIR Phone:209-9516745 <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(if present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name:TAN KNOLOGY INC. <br /> Technician Conducting Test:Gilbert Garcia <br /> Credentials: 11 CSLB Licensed Contractor ❑ SWRCB Licensed Tank Tester <br /> License Type:A HAZ License Number 743160 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> OPW SPILL BUCKET 2/42015 <br /> OPW SPILL BUCKET 2/42015 <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 rul 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 /> CERTIFICATION OF TECHNICL4N RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,,t�h�e/facts stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: Date: 10/172014 <br /> WO:2319458 <br />