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JAN 112017 <br /> SWRCB,January 2002 Pae 1 of 1 <br /> Secondary Containment Testing Report 1ENWIRONMENTAL HEALP <br /> DEPARTMENT <br /> This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the appropriate <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. FACILITY INFORMATION <br /> Facility Name:7-ELEVEN#19976,MKT 2368 jDate of Testing: 12/19/2016 <br /> Facility Address: 1399 N.MAIN ST. @ NORTHGATE,MANTECA,CA 95336 <br /> Facility Contact:BEN Phone:209-239-3252 <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(if present during testing):unknown <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name:TANKNOLOGY INC. <br /> Technician Conducting Test:Jarrod Cooke <br /> Credentials: +i CSLB Licensed Contractor r SWRCB Licensed Tank Tester <br /> License Type:a License Number:743160 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> tanknology all 5/18/2018 <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> Secondary Pipe Test(Tank T4-rul) X <br /> Secondary Pipe Test(Tank T5-pul) X <br /> Vapor Pipe for 1/2 3/4 to Fill sump X <br /> Vent Pipe for Reg fill to Vent box X <br /> Vent Pipe for Sup fill to Vent box X <br /> STP Containment for Tank T4 rul-I X <br /> STP Containment for Tank T5 pul-I X <br /> Vent Sump X <br /> UDC#1/2 X <br /> UDC#3/4 X <br /> Fill Containment for Tank:T4 rul-1 X <br /> Fill Containment for Tank:T5 pul-1 <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> taken water trailer <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,tt heeffac_ts stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: Cl""'---� Date: 12/19/2016 <br /> WO:2330376 <br />