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SWRCB, January 2002 <br />Secondary Containment Testing Report Form N 052 <br />This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use thea r <br />pages of this form to report results for all components tested. The completed form, written test procedures, a K r , <br />applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. % "1 TW ncn,%o-r� 41::W <br />1. FACILITY INFORMATION <br />Facility Name: 7 -ELEVEN #32262, MKT 2368 (N-3940-1 jDate of Testing: 12/7/2015 <br />Facility Address: 2360 W GRANTLINE I-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 />Technician Conducting Test: Jarrod Cooke <br />Credentials: W CSLB Licensed Contractor r—, SWRCB Licensed Tank Tester <br />License Tvne: a License Number: 743160 <br />Manufacturer Training <br />Manufacturer <br />Date <br />II tanknolo;?v all 5/16/2016 1 <br />3. SIJMMARY 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 />STP Containment for Tank T4 RUL reg unlead - <br />1 <br />X <br />STP Containment for Tank T5 MUL midgrade - 1 <br />x <br />STP Containment for Tank T6 PUL premium - 1 <br />X <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />taken/recvcled water trailer <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my knowledge, the <br />facts stated in this document are accurate and in full compliance with legal requirements <br />Technician's Signature: Date: 12/7/2015 <br />WO: 2324876 <br />