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SWRCB, January 2002 <br />• <br />Secondary Containment Testing Report Form <br />RECHV[ED <br />Page I of 1 <br />JAN 06 2016 <br />This form is intended for use by contractors performing periodic testing of UST secondary containment system.C-�( WQW. ENTAI <br />pages ofthis form to report results for all components tested. The completed form, written test procedures, and pr1WM*mgi vmGaAc'it(schtT <br />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 #32190, MKT 2368 Date of Testing: 12/16/2015 <br />Facility Address: 4943 S. KINGSLEY (FRONTAGE RD) HWY 99 @ ARCI I 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): not present <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: TANKNOLOGY INC. <br />Pass <br />Technician Conducting Test: Jarrod Cooke <br />Not <br />Tested <br />Credentials: r CSLB Licensed Contractor <br />r SWRCB Licensed Tank Tester <br />License Type: a <br />ILicense Number: 743160 <br />Manufacturer <br />Manufacturer Training <br />Component(s) Date Training Expires <br />tanknology <br />all 5/16/2016 <br />3. SUMMARY OF TEST RESULTS <br />Component <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />Component <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />STP Containment for Tank T4 not - 1 <br />X <br />STP Containment for Tank T5 mul - 1 <br />x <br />STP Containment for Tank T6 put - 1 <br />X <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />taken/recvcled water trailer <br />CERTMCATION OF TECHNICIAN RESPONSBLE FOR CONDUCTING THIS TESTING <br />To the best of my knowledge, <br />��the facts stated in this document are accurate and in full compliance with legal requirements <br />Technician's Signature: 17"`x� Date: 12/16/2015 <br />WO: 2324875 <br />