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SWRCB, January 2002 Page 1 of 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 appropriate <br /> pages of this form to report results for all components tested. The completed form, written test procedures, and printouts fr4orn 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-39404 Date of Testing: 12/21 /2018 <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 r6 SWRCB Licensed Tank Tester <br /> License Type: a ILicense Number: 743169 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> tanknology all 4/26/2020 <br /> 3 . SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> Secondary Pipe Test (Tank T4 RUL - reg unlead) X <br /> Secondary Pipe Test (Tank T4 RUL - reg unlead) x <br /> Secondary Pipe Test (Tank TS MUL - midgrade) X <br /> Secondary Pipe Test (Tank T5 MUL - midgrade) X <br /> Secondary Pipe Test (Tank T6 PUL - premium ) X <br /> Secondary Pipe Test (Tank T6 PUL - premium ) X <br /> UDC # 1 /2 X <br /> UDC # 3/4 x <br /> UDC # 5/6 X <br /> UDC # 7/8 X <br /> UDC # 9/10 X <br /> UDC # 11 /12 X <br /> If hydrostatic testing was performed, describe what was done with the water after completion of tests : <br /> taken water trailer <br /> CERTIFICATION OF TECBMCIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge, <br /> ��the facts stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature : CJp Date : 12/21 /2018 <br /> WO : 2339733 <br />