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i REGUVED <br />SWRCB, January 2002 APR 01 2016 Page 1 of I <br />Secondary Containment Testing Report FormENVIRONMENTAL <br />This form is intended for use by contractors performing periodic testing of UST secondary containrr4 RAr ,TtErRJ uagnpmq propriate <br />pages of this form to report results for all components tested. The completed form, written test procedures, and printouts from tests (if <br />applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1 FAd"T1 .ITV 1NFnDMAT1"W <br />Facility Name: 7 -ELEVEN #32190, MKT 2368 Date of Testing: 2/16/2016 <br />Facility Address: 4943 S. KINGSLEY (FRONTAGE RD) HWY 99 @ ARCH AIRPORT RD, STOCKTON, CA 95206 <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): andria <br />2. TESTING CONTRACTOR 1NFnRMAT1n1V <br />Company Name: TANKNOLOGY INC. <br />Pass <br />Technician Conducting Test: Jarrod Cooke <br />Not <br />Tested <br />Credentials: R CSLB Licensed Contractor <br />M S WRCB Licensed Tank Tester <br />License Type: a <br />Fail <br />ILicense Number: 743160 <br />Manufacturer <br />Manufacturer Trainine <br />Component(s) Date Training Expires <br />tanknology <br />all 5/16/2016 <br />3. SIJMMARV OF TFRT RFRIII T4 <br />Component <br />p <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />Component <br />Pass <br />Fail <br />Not <br />Testedl <br />Repairs <br />Made <br />Secondary Pipe Test (Tank T4 - rul) <br />x <br />Secondary Pipe Test (Tank T4 - rul) <br />x <br />Secondary Pipe Test (Tank T5 - and) <br />x <br />Secondary Pipe Test (Tank T5 - ran[) <br />x <br />Secondary Pipe Test (Tank T6 -put) <br />g <br />Secondary Pipe Test (Tank T6 -put) <br />x <br />UDC # 1/2 <br />x <br />UDC # 3/4 <br />X <br />UDC # 5/6 <br />x <br />UDC # 7/8 <br />X <br />UDC # 9/10 <br />x <br />UDC # 11/12 <br />x <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />taken/recycled water trailer <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my knowledge, them�e f'acts stated in this document are accurate and in full compliance with legal requirements <br />Technician's Signature: li9`Date: 2/16/2016 <br />WO: 2326934 <br />