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X. <br /> SWRCB,January 2002 Page 1 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:3/14/2014 <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: <br /> Name of Local Agency Inspector(if present during testing):not presant <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name:TANKNOLOGY INC. <br /> Technician Conducting Test:Jarrod Cooke <br /> Credentials: 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 /> tanknology all 5/16/2014 <br /> 3.SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs CgmpRnent Pass Fail Tested Not Repairs <br /> Tested Made „ a <br /> STP Containment for Tank Tl:rul-1 ){ g w <br /> STP Containment for Tank T2:put-1 x <br /> STP Containment for Tank T3:diesel-1 X <br /> #g <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> taken/recycled water trailer <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,,thefacts stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: _ Date: 3/14/2014 <br /> WO:2317502 <br />