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SWRCR,January 2002 Page 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 <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: 03/17/2010 <br /> Facility Address: 4627 DA VINCI DR @ MARCH LN, STOCKTON, CA, 95207 <br /> Facility Contact: MGR - SATB I R (PTO# N-748) Phone: (2 0 9) 952-3543 <br /> Date Local Agency Was Notified of Testing: 03/11/2010 <br /> Name of Local Agency Inspector(if present during testing): garrett <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TANKNOLOGY, INC. <br /> Technician Conducting Test: STEVEN WILLEMS <br /> Credentials: CSLB Licensed Contractor ❑ SWRCB Licensed Tank Tester <br /> License Type: icc License Number: 8016974 ut <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> opW spill bucket 06/25/2010 <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 E ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Spill Box 2 PRE FILL x ❑ ❑ ❑ ❑ ❑ ❑ <br /> El El El El El <br /> El I F1 El El 1:1 El 1:1 E <br /> El I El El El El F� F1 <br /> El E El D F] 0 . <br /> M F-1 F-1 El El E <br /> ❑ ❑ ❑ ❑ El ❑ 01 <br /> El F-1 El El El El <br /> F-1 El- <br /> F-1 ❑ ❑ ❑ <br /> E ❑ E <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> put in drum and label <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: 03/17/2010 <br />