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SWRCB, January 2002 <br />ECE`WEV <br />NOV 3 0 2017 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 con t�i'�LIi��iA�TLp[HEATH <br />pages of this form to report results for all components tested. The completed form, written test procedure`�E,�t�rTM?1th tests (f <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 # 17647, MKT 2368 (N-744) IDate of Testing: 11/27/2017 <br />Facility Address: 1048 W. YOSEMITE AVE @ EL PORTEL, MANTECA, CA 95336 <br />Facility Contact: DEALER-ANTWAN Phone: 209-239-2329 <br />Date Local Agency Was Notified of Testing: 11/16/2017 <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 />Not <br />Tested <br />Credentials: r CSLB Licensed Contractor <br />i— SWRCB Licensed Tank Tester <br />License Type: 743160 <br />License Number: a <br />Manufacturer <br />Manufacturer Trainine <br />Component(s) Date Training Expires <br />tanknology <br />all 4/26/2020 <br />3. SUMMARY OF TEST RESULTS <br />ComponentPass <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 />Tank Annular# T-1 <br />x <br />Tank Annular# T-2 <br />x <br />Secondary Pipe Test (Tank T-1 - to]) <br />x <br />Secondary Pipe Test (Tank T-2 -put) <br />x <br />STP Containment for Tank T-1 .1 - 1 <br />x <br />STP Containment for Tank T-2 put - I <br />x <br />UDC # 1/2 <br />x <br />UDC # 3/4 <br />x <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />CERTIFICATION OF TECIINICIAN RESPONSIBLE FOR CONDUCTING TIUS TESTING <br />To the best of my knowledge, tt--heef�facts stated in this document are accurate and in full compliance with legal requirements <br />Technician's Signature: Date: 1127/2017 <br />WO: 2332830 <br />