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k SWRCB, January 2002 Page 1. Secondary Containment Testing Report Form This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the appropriate pages of this form to report results for all components tested. The completed form, written test procedures, and printouts from tests (f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. 1. FACILITY INFORMATION Facility Name: 7 -ELEVEN #19976, MKT 2368 Date of Testing: 10/08/2010 Facility Address: 1399 N. MAIN ST. @ NORTHGATE , MANTECA, CA, 95336 Facility Contact: BEN Phone: (2 0 9) 23 9-3252 Date Local Agency Was Notified of Testing: 09/28/2010 Name of Local Agency Inspector (if present during testing): thuy tran 2. TESTING CONTRACTOR INFORMATION Company Name: TANKNOLOGY , INC. Pass Fail Technician Conducting Test: CHARLES FERRUCCI Component Pass Credentials: Not Tested CSLB Licensed Contractor Spill Box 4 REG FILL SWRCB Licensed Tank Tester ❑ ❑ License Type: 7 43160 License Number: 743160 ❑ ❑ Manufacturer Manufacturer Training Component(s) Date Training Expires pomeco SPILL BUCKET ❑ ❑ ❑ ❑ - ❑ 11 3. SUMMARY OF TEST RESULTS Component Pass Fail Not Tested Repairs Made Component Pass Fail Not Tested Repair Made Spill Box 4 REG FILL El ❑ ❑ ❑ ❑ ❑ ❑ F -1 Spill Spill Box 5 PRE FILL Fx] ❑ ❑ ❑ ❑ ❑ ❑ - ❑ 11 El EI LI F1 F1 El F] El El - Fl F] o 1:1 E 1:1 1:1 1:1 - E 0 El El 11 El El El El El El Ej F7 F1 El E] El El El 1:1 1:1 1:1 Ll El El El El El El El El El El El El El El El El El El Ll Ll El El 1:1 El El 1 10101 El I El 1 1:11 El E If hydrostatic testing was performed, describe what was done with the water after completion of tests: water taken off site CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING To the best of my knowledge, the facts stated in this document are accurate and in full compliance with legal requirements Technician's Signature: Date: 10/08/2010