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S WRCB, January 2002 <br />Secondary Containment Testing Report Form <br />Page 1 . <br />This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the <br />appropriate pages of this form to report results for all components tested. The completed form, written test procedures, and <br />printouts from tests (f 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 #19976, MKT 2368 <br />DateofTesting: 10/03/2011 <br />Facility Address: 1399 N. MAIN ST. @ NORTHGATE, MANTECA, CA, 95336 <br />Facility Contact: BEN- (PERMIT: N-745-1-4) <br />Phone: (209) 239-3252 <br />Date Local Agency Was Notified of Testing : / / <br />Name of Local Agency Inspector (if present during testing): THUY <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: TANKNOLOGY, <br />INC. <br />Technician Conducting Test: TIMOTHY COULTER <br />Credentials: <br />❑x <br />CSLB Licensed Contractor SWRCB Licensed Tank Tester <br />License Type: UT -A <br />Spill Box 4 REG FILL <br />I License Number: 5295244-734160 <br />Manufacturer <br />Manufacturer Trainine <br />Component(s) <br />Date Training Expires <br />OPW <br />SPILL BUCKETS <br />04/17/2012 <br />Spill Box 5 PRE FILL0000 <br />��00 <br />3. SUMMARY OF TEST RESULTS <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />TOOK FROM SITE <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS 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: � r-- Date: 10/03/2011 <br />Spill Box 4 REG FILL <br />Spill Box 5 PRE FILL0000 <br />��00 <br />000 <br />��00 <br />0000 <br />��00 <br />0000 <br />��00 <br />�D00 <br />��00 <br />000 <br />��00 <br />0000 <br />a000 <br />0000 <br />0000 <br />0000 <br />0000 <br />0000 <br />0000 <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />TOOK FROM SITE <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS 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: � r-- Date: 10/03/2011 <br />