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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 (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. 1. FACILITY INFORMATION FacilityName: 7 -ELEVEN #19976, MKT 2368 Date of Testing: 12/01/2008 Facility Address: 1399 N. MAIN ST. @ NORTHGATE, MANTECA, CA, 95336 Facility Contact: BEN Phone: (2 0 9) 23 9-32 5 2 Date Local Agency Was Notified of Testing Name of Local Agency Inspector (if present during testing): 2. TESTING CONTRACTOR INFORMATION Company Name: TANKNOLOGY, INC. Pass Fail Not Tested Technician Conducting Test: STEVEN WILLEMS Pass Fail Credentials: Repair Made CSLB Licensed Contractor 11 -, 11 SWRCB Licensed Tank Tester ❑ ❑ License Type: I License Number: ❑ ❑ Manufacturer Manufacturer Training Component(s) Date Training Expires ❑ ❑ ❑ E ❑ El 171 E El Ll 3. SUMMARY OF TEST RESULTS Component Pass Fail Not Tested Repairs Made Component Pass Fail Not Tested Repair Made Spill Box 4 REG FILL 11 -, 11 ❑ ❑ ❑ ❑ ❑ ❑ ❑ Spill Box 5 PRE FILL X ❑ ❑ ❑ E ❑ El 171 E El Ll 1:1 El El El 11 El El 0 - 0 0 El E] 11 El El El EJ F1 El El El 1:1 El D El E] 1:1 1:1 1:1 El El El El El El El El El El El El EJ El El 1:1 El El D Ll Ll E 1:1 El El El D 1:1 El If hydrostatic testing was performed, describe what was done with the water after completion of tests: 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: 12/01/2008