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SWRCB,January 2002 Page I of 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 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 submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name:7 ELEVEN 35355 jDate of Testing:2/27/2014 <br /> Facility Address:3202 W HAMMER LANE ,STOCKTON,CA 95209 <br /> Facility Contact:MANAGER Phone:209-957-2900 <br /> Date Local Agency Was Notified of Testing:2/27/2014 <br /> Name of Local Agency Inspector(if present during testing): <br /> 2.TESTING CONTRACTOR INFORMATION ENVIRONMENTAL HEALTH <br /> Company Name:TANKNOLOGY INC. DEPARTMENT <br /> Technician Conducting Test:Brent Bowen <br /> Credentials: F7, CSLB Licensed Contractor SWRCB Licensed Tank Tester <br /> License Type:a ILicense Number:743160 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> opw spill buckets 2/2/2015 <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 T1:rul fill X <br /> Spill Box T2:pul fill X <br /> Spill Box T3:diesel fill X <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> too test water with me <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: 2/27/2014 <br /> WO:2315745 <br />