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SWRCB, January 2002 <br />Page 1 of 1 <br />Secondary Containment Testing Report Form <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 <br />(if 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 <br />IDate of Testing: 12/19/2012 <br />Facility Address: 1399 N. MAIN ST. @ NORTHGATE, MANTECA, CA 95336 <br />Facility Contact: BEN Phone: 239-3252 <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: Steven Willems <br />Not <br />ested <br />Credentials: yr CSLB Licensed Contractor <br />r- SWRCB Licensed Tank Tcstcr <br />License Type: tanknology License Number: 743160 <br />Manufacturer <br />Nlanufacturer Yrainino. <br />Component(s) Date Training Expires <br />tanknology <br />secondary containment 9/2/2013 <br />X <br />3. SUMMARY OF TEST RESULTS <br />Component <br />Pass <br />Fail <br />Not <br />ested <br />lZepairs <br />11ade <br />Component <br />Pass <br />FailNot <br />bested <br />Repairs <br />Made <br />Tank Annular# 4 <br />X <br />Tank Annular# 5 <br />Secondary Pipe Test (Tank 4 - rul) <br />x <br />Secondary Pipe Test (Tank 5 - pul) <br />x <br />STP Containment for Tank 4 rul - 1 <br />x <br />STP Containment for Tank 5 pul - 1 <br />x <br />UDC # 1/2 <br />x <br />UDC # 3/4 <br />x <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: put in waterdog and take with <br />me <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my knowledge, the'falcts stated in this document are accurate and in full compliance with legal requirements <br />Technician's Signature: w'"` Date: 12/19/2012 <br />WO: 2306815 <br />