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SWRCB,January 2002 Page 1 of I <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 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#17334 MKT 2368(N-747) Date of Testing:9/9/2015 <br /> Facility Address:4501 N.PERSHING AVE. ROSEMARIE LN,STOCKTON,CA 95207 <br /> Facility Contact:MGR-SATBIR Phone:209-951-6745 <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 SFp 9, 4 2M <br /> Company Name:TANKNOLOGY INC. 11 <br /> Technician Conducting Test:Jarrod Cooke i=KWIRCINL. <br /> Credentials: 17' CSLB Licensed Contractor F- SWRCB Licensed Tank Tester (4CptTV nCo50Tst <br /> License Type:aLicense Number:743160 <br /> Manufacturer Training <br /> Manufacturer Components) Date Training Expires <br /> tanknology all 5/16/2016 <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Repairs Not Repairs <br /> Component Pass Fail Tested Made Component Pass Fail Tested Made <br /> Tank Annular#T-1 x <br /> Tank Annulate T-2 x <br /> Secondary Pipe Teel(Tank T-1-ran x <br /> Secondary Pipe Test(Tank T-2-put) x <br /> STP Containment for Tank T-1 rul-1 x <br /> STP Containment for Tank T-2 put-1 x <br /> UDC#1/2 x <br /> UDC#3/4 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 knowledgee,/,��t�he facts stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: 17"`y—� Date: 9/9/2015 <br /> WO:2324076 <br />