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SWRCB, January 2002 Page 1 of I <br /> Secondary Containment Testing Report Form <br /> This form is intended for use by contsractors performing periodic testing of UST secondary containment systems. Use the appropriate <br /> pages of this form to report results for all components tested. The completed form, written test procedures, and printouts from tests (if <br /> applicable), should be provided to the facility owner/operator for• slibrnittal to the local regulatory agency. <br /> 1 . FACILITY INFORMATION <br /> Facility Name: 7-ELEVEN #20632, MKT 2368 jDate of Testing : 10/ 10/2018 <br /> Facility Address: 4627 DA VINCI DR @ MARCH LN, STOCKTON, CA 95207 <br /> Facility Contact: MGR - SATBIR (PTO# W48) Phone: 209-952-3543 <br /> Date Local Agency Was Notified of Testing : 10/ 10/2018 <br /> Name of Local Agency Inspector ( if present during testing) : not present <br /> 2 . TESTING CONTRACTOR INFORMATION <br /> Company Name: TANK NOLOGY INC. <br /> Technician Conducting Test : Jarrod Cooke <br /> Credentials : CSLB Licensed Contractor SWRCB Licensed Tank Tester <br /> License Type: a License Number: 743160 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> tanknology all 4/26/2020 <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# TLRUL X <br /> Tank Annular# TIPUL x <br /> If hydrostatic testing was performed, describe what was done with the water after completion of tests : <br /> taken water trailer <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of nay knowledge, <br /> �the facts stated in this document are accurate and in fall compliance with legal requirements <br /> Technician' s Signature : Date : 10/10/2018 <br /> W0 : 2338786 <br />