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SWRCB, January 2002 Page 1. Secondary Containment Testing Report Form This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the appropriate pages of this form to report results for all components tested. The completed form, written test procedures, and printouts from tests (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. 1. FACILITY INFORMATION Facility Name: 7 -ELEVEN # 19976 MKT 2237 DateofTesting: 02/14/2006 Facility Address: 1399 N. MAIN ST. MANTECA, CA, 95336 Facility Contact: BEN Phone: (2 0 9) 239-3252 Date Local Agency Was Notified of Testing Name of Local Agency Inspector (if present during testing): 2. TESTING CONTRACTOR INFORMATION Company Name: TANKNOLOGY , INC. Technician Conducting Test: ANEIL CHAND Credentials: CSLB Licensed Contractor SWRCB Licensed Tank Tester Spill Box REGULAR License Type: License Number: Manufacturer Manufacturer Training Component(s) Date Training Expires Spill Box PREMIUM 00m0 ��00 3. SUMMARY OF TEST RESULTS If hydrostatic testing was performed, describe what was done with the water after completion of tests: CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING To the best of my knowledge, the facts stated in this document are accurate and in full compliance with legal requirements Technician's Signature: Date: 02/14/2006 Repairs Made Spill Box REGULAR 00m0 ��00 Spill Box PREMIUM 00m0 ��00 000 ��00 If hydrostatic testing was performed, describe what was done with the water after completion of tests: CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING To the best of my knowledge, the facts stated in this document are accurate and in full compliance with legal requirements Technician's Signature: Date: 02/14/2006