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Page 1. <br /> Secondary Containment Testing Report Form <br /> or use by contractors performing periodic testing of UST secondary containment systems. Use the <br /> this form to report results for all components tested. The completed form, written test procedures,and <br /> (f applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> 7-ELEVEN #19976, MKT 2368 Date of Testing: 11/06/2009 <br /> Fac.. dress: 1399 N. MAIN ST. @ NORTHGATE, MANTECA, CA, 95336 <br /> Facility Contact: BEN Phone: (2 0 9) 23 9-3252 <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(if present during testing): MOONIE <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TANKNOLOGY, INC. <br /> Technician Conducting Test: KRISTOPHER BELL <br /> Credentials: CSLB Licensed Contractor SWRCB Licensed Tank Tester <br /> License Type: License Number: 5297793-UT <br /> Manufacturer Trainine <br /> Manufacturer Component(s) Date Training Expires <br /> OPW INSTALATION <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Repairs Not Repair <br /> Component Pass Fail Tested Made Component Pass Fail Tested Ma <br /> de <br /> Spill Box 4 REG FILL ❑ ❑ ❑ ❑ ❑ <br /> Spill Box 5 PRE FILL x ❑ ❑ ❑ ❑ ❑ El ❑ <br /> Spill Box 4 REG FILL x ❑ ❑ ❑ ❑ ❑ ❑ <br /> El El El E E E <br /> El F1 El El El D <br /> El El El El F] El <br /> El El El E El El <br /> El F-1 El 1:1 El F-1 El E <br /> El El El 1:1 El E El <br /> El r� El El El 11 El El <br /> El El El D 1:1 11 El El <br /> El E:1 El El 1:1101 E <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> LEFT IN DRUM ONSITE <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: 11/06/2009 <br />