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SWRCB,January 2002 Page 1. <br /> Second• Containment Testing Report Form <br /> This form is intended for use by contractors performingperiodic testing of USTsecondary 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(tf applicable),should beprovided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> FacilityName: 7-ELEVEN #32190, MKT 2368 Dateof Testing: 02/22/2010 <br /> Facility Address: 4943 S. KINGSLEY (FRONTAGE RD) HWY 99 @ ARCH AIRPORT RD, STOCKTON, CA, <br /> Facility Contact: MGR - LORENA Phone: (209) 939-0679 <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(if present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TANKNOLOGY, INC. <br /> Technician Conducting Test: JARROD COOKE <br /> Credentials: ❑x CSLB Licensed Contractor SWRCB Licensed Tank Tester <br /> License Type: a I License Number: 743160 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> tanknology all 07/18/2011 <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Repairs Not Repair <br /> Component Pass Fail Tested Made Component Pass Fail Not <br /> Made <br /> Secondary Pipe 5 MID PLUSA E ❑ ❑ ❑ El El El El <br /> Piping Sump 6 PRE El ❑ ❑ 1:1 El El El El <br /> El El Ej 1:1 Ej Ej El El <br /> El El El E 01E <br /> El I El El El El El E <br /> ❑ 10 ❑ ❑ ❑ I ❑ I ❑ ❑ <br /> El I El 1:1 El El El Ej El <br /> El I El El El El El El Ej <br /> ❑ ❑ ❑ Eli ❑ ❑ ❑ <br /> El I El El El El El El <br /> El El 11 El El El El El <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> taken water dog <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 infill compliance with legal requirements <br /> Technician's Signature: Date: 02/22/2010 <br />