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SWRCB, January 2002 <br />11 <br />Secondary Containment Testing Report Form <br />Page 1 of 1 <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 #32262, MKT 2368 (N-3940-1 jDate of Testing: 2/10/2016 <br />Facility Address: 2360 W GRANTLINE 1-205 OFF RAMP, TRACY, CA 95376 <br />Facility Contact: CHANDRA Phone: 209-830-9917 <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 />17 U5 15 z <br />Technician Conducting Test: Jarrod Cooke <br />Credentials: r7i CSLB Licensed Contractor <br />rl SWRCB Licensed Tank Tester ENVIRONME <br />License Type: a <br />Manufacturer <br />License Number: 743160 <br />Manufacturer Training <br />Component(s) Date Training Expires <br />tanknology <br />all 5/16/2016 <br />Not <br />Tested <br />Repairs <br />Made <br />Secondary Pipe Test (Tank T4 RUL - reg unlead) <br />x <br />L- <br />I <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 />Repairs <br />Made <br />Secondary Pipe Test (Tank T4 RUL - reg unlead) <br />x <br />Secondary Pipe Test (Tank T4 RUL - reg unlead) <br />x <br />Secondary Pipe Test (Tank T5 MUL - midgrade) <br />x <br />Secondary Pipe Test (Tank T5 MUL - midgrade) <br />x <br />Secondary Pipe Test (Tank T6 PUL - premium) <br />x <br />Secondary Pipe Test (Tank T6 PUL - premium) <br />x <br />UDC # 1/2 <br />X <br />UDC # 3/4 <br />x <br />UDC # 5/6 <br />x <br />UDC # 7/8 <br />x <br />UDC # 9/10 <br />x <br />UDC # 11/12 <br />x <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />taken/recycled water trailer <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my knowledge,, thefacts stated in this document are accurate and in full compliance with legal requirements <br />Technician's Signature: 179 Date: 2/10/2016 <br />WO: 2326766 <br />