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REG§?!ta�'tm ., � ep r�J¢ gra <br />oar. I.� i �ae�rm <br />SWRCB, January 2002 <br />Secondary Containment Testing Report Form AUG 0 7 2017 <br />This form is intendedfor use by contractors perfbi-ming 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, wri{eA#Proq�dures, .and r EALTH <br />printouts from tests (f applicable), should be provided to the facility owner/operator for submittal to he I cul re etlatoryagen <br />1. FACILITY INFORMATION UARI HENT <br />Facility Name: 7 -Eleven #19976 1 Date of Testing: 07/17/17 <br />Facility Address: 1399 N. Main Street, Manteca, CA 95336 <br />Facility Contact: NIA I Phone: (209) 239-3252 <br />Date Local Agency Was Notified of Testing: 06/27/17 @ 10:08am via email <br />Name of Local Agency Inspector (if present during testing): Not Present <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: CGRS, Inc. <br />Pass <br />Technician Conducting Test: Richard Thomas <br />Not <br />Tested <br />Credentials: ® CSLB Licensed Contractor ® SWRCB Licensed Tank Tester <br />Pass <br />License Type: C6111340064 803616 (CSL B L,ic. i License Number: 803616 (CSLB Lic.) <br />06-1672 (SWRCB Lic.) <br />Manufacturer Trainine <br />Manufacturer Component(s) <br />Date Training Expires <br />ICC CA UST SERVICE TECHNICIAN: #5254736 <br />11/17/2018 <br />ICC UST TANK TIGHTNESS TESTING: #5254736 <br />03/08/2018 <br />SCWRCB TANK TESTER LICENSE: #06-1672 <br />06/30/2018 <br />FRANKLIN FUELING INCON SUMP TESTER: #1001773708 <br />02/06/2019 <br />3. SUMMARY OF TEST RESULTS <br />Component <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs Component <br />Made <br />Pass <br />Fail <br />NotRepairs <br />Tested Made ; <br />-4 87 Secondary Product Line <br />1T-4 <br />® <br />El <br />F1 <br />El <br />El <br />F-1 <br />E] El <br />T-4 87 Secondary Vent Line <br />® <br />El <br />El <br />El <br />1:1 <br />1:1 <br />El ElT <br />87 STP Sump <br />® <br />❑ <br />❑ <br />I ❑ <br />❑ <br />❑ <br />❑ 1 ❑ <br />T-4 87 Fill Sump <br />® <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ ❑ <br />T-5 91 Secondary Product Line <br />® <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ ❑ <br />T-5 91 Secondary Vent Line <br />® <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ ❑ <br />T-5 91 STP Sump <br />® <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ ❑ <br />T-5 91 Fill Sump <br />® <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ ❑ <br />Vapor Recovery Secondary Line <br />® <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ ❑ <br />UDC #1.2 <br />® <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ ❑ <br />UDC #3-4 <br />® <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ ❑ <br />Vent Transition Box <br />® <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ ❑ <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />TECHNICIAN CARRIES A 535 GALLON TANK FOR TESTING WATER <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:` J�5 Date: 07/17/17 <br />