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SWRCB,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 DateofTesting: 03/31/2009 <br /> Facility Address: 4627 DA VINCI DR Q MARCH LN, STOCKTON, CA, 95207 <br /> Facility Contact: MGR - SATB IR (PTO# N-748) Phone: (2 0 9) 952-3543 <br /> Date Local Agency Was Notified of Testing : / / <br /> Name of Local Agency Inspector(if present during testing): GARRETT BACKUS <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TANKNOLOGY, INC. <br /> Technician Conducting Test: JOEY MESA <br /> Credentials: CSLB Licensed Contractor SWRCB Licensed Tank Tester <br /> License Type: ICC SERVICE I License Number: 5259458-UT <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> OPW SPILL BUCKET 12/18/2010 <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 ❑ ❑ ❑ ❑ ❑ ❑ 0- <br /> Spill Box 2 PRE FILL X ❑ ❑ ❑ ❑ ❑ El ❑ <br /> E El E <br /> M El El El El El ELI <br /> El I ❑ 1 ❑ ❑ ❑ ❑ El- <br /> El <br /> F-1 El El Ell Ell EJ I El I <br /> El El ❑ El <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> El I El El El El F-1 <br /> El F-1 F-1 El El El El <br /> Ell Eli El I El i I Ell El <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> LEFT ONSITE. <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: l r/ Date: 03/31/2009 <br />