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SWRCB, Janudry 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 />Date of Testing: 01/05/2010 <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): na <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: TANKNOLOGY, INC. <br />Pass <br />Technician Conducting Test: <br />JARROD COOKE <br />Repairs <br />Made <br />Credentials: <br />Pass <br />CSLB Licensed Contractor <br />Not <br />Tested <br />SWRCB Licensed Tank Tester <br />Secondary Pipe 4 REG A <br />License Type: a <br />License Number: 7 4 316 0 <br />[K] <br />Manufacturer <br />Manufacturer Training <br />Component(s) <br />Date Training Expires <br />tanknology <br />all <br />07/18/2011 <br />Secondary Pipe 4 REG B1:1 <br />El <br />❑ <br />UDC 9/10 <br />� <br />❑ <br />❑ <br />3. SUMMARY OF TEST RESULTS <br />Component <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />Component <br />Pass <br />Fail <br />Not <br />Tested <br />Repair <br />Ma de <br />Secondary Pipe 4 REG A <br />1:1 <br />[K] <br />❑ <br />UDC 7/8 <br />a <br />a <br />❑ <br />❑ <br />Secondary Pipe 4 REG B1:1 <br />El <br />❑ <br />UDC 9/10 <br />� <br />❑ <br />❑ <br />❑ <br />Secondary Pipe 5 MID A <br />❑ <br />1:1 <br />a <br />❑ <br />UDC 11/12 <br />Q <br />1:1 <br />❑ <br />0 <br />Secondary Pipe 5 MID B <br />Secondary Pipe 6 PRE A <br />❑ <br />a <br />El <br />❑ <br />❑ <br />El <br />❑ <br />El <br />Secondary Pipe 6 PRE B <br />❑ <br />a <br />' <br />❑ <br />❑ <br />❑ <br />❑ <br />Piping Sump 4 REG <br />❑ <br />1:1 <br />❑ <br />1:1 <br />❑ <br />❑ <br />❑ <br />Piping Sump 6 PRE <br />a <br />a❑ <br />0 <br />0 <br />0 <br />0 <br />0 - <br />Piping Sump 5 MID <br />a <br />El <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />E <br />UDC 1/2 <br />❑ <br />❑ <br />❑ <br />El <br />❑ <br />El <br />El <br />UDC 3/4 <br />❑ <br />1:1 <br />a <br />❑ <br />El <br />UDC 5/6 <br />El <br />El <br />❑ <br />❑ <br />a <br />❑ <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />taken pump truck <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: 01/05/2010 <br />