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Q " �. <br />vu sP'w <br />SWRCB, January 2002/�� Page I of I <br />Secondary Containment Testing Report Form <br />o <br />This form is intended for use by contractors performing periodic testing of UST secondary contain t stern tis likerpro�rtate <br />pages of this form to report results for all components tested. The completed form, written test proceduvw- rom 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 Date of Testing: 9/13/2013 <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): garrett <br />2. 4'ES l 1N G COIN I MAUI UK 1N V OKTVIA l ION <br />A CITMMARV OF TF.CT RFCITI,TC <br />Component <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />Component <br />Pass <br />Fail <br />Not <br />Tested I <br />Repairs <br />Made <br />UDC # I/2 <br />X <br />UDC # 3/4 <br />X <br />UDC # 5/6 <br />X <br />UDC # 7/8 <br />X <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />put water back in water wagon and take 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: 9/13/2013 <br />WO: 2314294 <br />