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SWRCB, January 2002 Pae 1 <br />Secondary Containment Testing Report Form R EC E tD <br />This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use thhrom �nria� 16 <br />pages of this form to report results for all components tested. The completed form, written test procedures, and printou s tests tf <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: 12/18/2015 <br />facility Address: 1399N. MAIN ST. @ NORTHGATE, MANTECA, CA 95336 <br />Facility Contact: BEN Phone: 209-239-3252 <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 />ENVIRONMENTAL <br />ur:Al Tw ni=PARTMENT <br />Company Name: TANKNOLOGY INC. <br />Pass <br />Technician Conducting Test: Jarrod Cooke <br />Not <br />Tested <br />Credentials: r CSLB Licensed Contractor <br />rl SWRCB Licensed Tank Tester <br />License Type: a <br />Dail <br />ILicense Number: 743160 <br />Manufacturer <br />Manufacturer Training <br />Component(s) Date Training Expires <br />tanknology <br />all 5/16/2016 <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 />Dail <br />Not <br />Not <br />Repairs <br />Nlade <br />STP Containment for Tank T4 rul - 1 <br />x <br />STP Containment for Tank T5 pul - 1 <br />x <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />taken/recycled water trailer /// UDC's and piping were not testable. Per CA regulations the test ports were removed from the piping <br />secondary in each dispenser. Maintenance was notified to replace the plugs to allow for testing. <br />CERTIFICATION OF TECHMCIAN RESPONSIBLE FOR CONDUCTING TINS TESTING <br />To the best of my knowledge, tt he�fac_ts stated in this document are accurate and in full compliance with legal requirements <br />Technician's Signature: C/v Date: 12/18/2015 <br />WO: 2324873 <br />