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SWRCB, January 2002 <br />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 systTiis. (C ee di f..1j pages of thisform to report resultsfor all components tested The completedform, written testprocedures, (ind p-bgg <br />applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION JAN 0 5 2010' <br />Facility Name: 7 -ELEVEN #19976, MKT 2368 jDate of Testing: 12/18/2015 <br />Facility Address: 1399 N. MAIN ST. @ NORTHGATE, MANTECA, CA 95336 <br />Facility Contact: BEN Phone: 209-239-3252 It <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 />Pass <br />Technician Conducting Test: Jarrod Cooke <br />Not <br />Tested <br />Credentials: r CSLB Licensed Contractor <br />r SWRCB Licensed Tank Tester <br />License Type: a <br />1l.icense 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 />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />STP Containment for Tank T4 rul - I <br />STP Containment for Tank T5 pul - I <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />taken/recycled water trailer <br />CERTH'ICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my knowledge, <br />tthe�facts stated in this document are accurate and in full compliance with legal requirements <br />Technician's Signature: Date: 12/18/2015 <br />WO: 2324873 <br />