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SWRCB, January 2002 <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 nrintr tif <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 # 19976, MKT 2368 jDate of Testing: 1/19/2016 <br />Facility Address: 1399N. MAIN ST. @ NORTHGATE, MANTECA, CA 95336 <br />Facility Contact: BEN Phone: 209-239-3252 ENVIRONMENTA <br />Date Local Agency Was Notified of Testing: HEALTH DEPARTIVIE <br />Name of Local Agency Inspector (if present during testing): Andrea <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: TANKNOLOGY INC. <br />Pass <br />Technician Conducting Test: Jarrod Cooke <br />Not <br />Tested <br />Credentials: r CSLB Licensed Contractor <br />r.1 SWRCB Licensed Tank Tester <br />License Type: A <br />1 License Number: 8155550 <br />Manufacturer <br />Manufacturer Training <br />Component(s) Date Training Expires <br />Tanknology <br />All 5/19/2017 <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) <br />X <br />Secondary Pipe Test (Tank T5 - pul) <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 />taken/recycled water trailer <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my knowledge, the facts stated in this document are accurate and in full compliance with legal requirements <br />Technician's Signature: Date: 1/19/2016 <br />WO: 2326433 <br />NT <br />