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SWRCB, January 2002 Page 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 <br />appropriate pages of this form to report results for all components tested. The completed form, written test procedures, and <br />printouts from tests (f 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 #32262, MKT 2368 (N-3940) <br />I DateofTesting: 02/15/2010 <br />Facility Address: 2360 W GRANTLINE I-205 OFF RAMP, TRACY, CA, 95376 <br />Facility Contact: CHANDRA <br />Phone: (2 0 9) 830-9917 <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agency Inspector (if present during testing): <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: TANKNOLOGY, INC. <br />Technician Conducting Test: <br />JARROD COOKE <br />Credentials: <br />CSLB Licensed Contractor <br />Secondary Pipe 4 REG =Elm <br />SWRCB Licensed Tank Tester <br />"M <br />License Type: <br />Manufacturer <br />I License Number: <br />Manufacturer Training <br />Component(s) <br />Date Training Expires <br />Secondary Pipe 4 REG B <br />110 R <br />Secondary Pipe 5 MID A <br />Component <br />Secondary Pipe 4 REG =Elm <br />"M <br />Secondary Pipe 4 REG B <br />110 R <br />Secondary Pipe 5 MID A <br />Secondary Pipe 6 PRE A <br />Secondary Pipe 6 PRE B <br />IWIoo <br />0000 <br />�000 <br />oo�o <br />0000 <br />000 <br />0000 <br />0000 <br />0000 <br />0000 <br />� <br />oo�o <br />0000 <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <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: Date: 02/15/2010 <br />