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SWRCB,January 2002 Page 1. <br /> Second Containment Testing Rept 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 /> Facility Name: 7-ELEVEN #20632, MKT 2368 Date of Testing: 02/17/2011 <br /> Facility Address: 4627 DA VINCI DR @ MARCH LN, STOCKTON, CA, 95207 <br /> Facility Contact: MGR - SATBIR (PTO# N-748) Phone: (209) 952-3543 <br /> Date Local Agency Was Notified of Testing: / / <br /> Name of Local Agency Inspector(if present during testing): GARETT <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TANKNOLOGY, INC. <br /> Technician Conducting Test: KRISTOPHER BELL <br /> Credentials: E CSLB Licensed Contractor SWRCB Licensed Tank Tester <br /> License Type: CONTRACTOR I License Number: 743160 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> OPW INSTALATION 09/01/2011 <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Repairs Not Repair <br /> ss <br /> Component Pass Fail Tested Made Component Pass Fail Tested Made <br /> Spill Box 1 REG FILL FRI ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Spill Box 2 PRE FILL x ❑ ❑ ❑ ❑ ❑ ❑ <br /> 0 F] 0 0 Ell 0 0 El <br /> ❑ I ❑ I ❑ 0 ❑ 0 0 <br /> 0 0 F-1 0 0 0 ❑ E <br /> 0 0 0 0 1Eli I0 <br /> F1 0 0 0 F-1 0 <br /> El F-10 ❑ ❑ 0 El <br /> El 0 0 0 0 El <br /> 0101 0 0 El0 0 <br /> El 0 0 El 0 E <br /> Ell 01 0 0 El 0 0 <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> TOOK 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: I-V I Date: 02/17/2011 <br />