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SWRCB, January 2002 <br />Page 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 <br />appropriate pages of this form to report results for all components tested. The completed form, written test procedures, and <br />printouts from tests (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />FacilityName: 7 -ELEVEN #19976, MKT 2237 <br />DateofTesting: 01/02/2008 <br />Facility Address: 1399 N. MAIN ST. @ NORTHGATE, MANTECA, CA, 95336 <br />Facility Contact: BEN <br />Phone: (2 0 9) 2 3 9- 3 2 52 <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: TANKNOLOGY, INC. <br />Technician Conducting Test: <br />HEATH MCEVER <br />Credentials: <br />❑ <br />CSLB Licensed Contractor <br />SWRCB Licensed Tank Tester <br />License Type: SERVICE TECH <br />License Number: 5236756 -UT <br />Manufacturer <br />Manufacturer Training <br />Component(s) <br />Date Training Expires <br />OPW <br />SPILL BUCKET <br />06/13/2008 <br />Spill Box S PRE FILL000 <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 />PLACED IN DRUM ON 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: / Date: 01/02/2008 <br />Spill Box 4 REG FILL000 <br />��00 <br />Spill Box S PRE FILL000 <br />��00 <br />a000 <br />0000 <br />0000 <br />0000 <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 />PLACED IN DRUM ON 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: / Date: 01/02/2008 <br />