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SWRCB,January 2002 Page I of I <br /> Secondary Containment Testing Report Form <br /> This form is intended for use by contractors performing periodic testing of UST secondary containment syRe sef1ts <br /> e VED <br /> pages ofthisform to report results for all components tested. The completedform, written testprocedures, nt m to <br /> .> <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 35355 jDate of Testing:9/4/2014 <br /> Facility Address:3202 W HAMMER LANE ,STOCKTON,CA 95209 -j <br /> Facility Contact:MANAGER Phone:209-957-2900 DEIRARTA4 NT <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 /> Technician Conducting Test:Jarrod Cooke <br /> Credentials: P7 CSLB Licensed Contractor r SWRCB Licensed Tank Tester <br /> License Type:a License Number:743160 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> tanknology all 5/16/2016 <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> Tank Annular#1 X UDC#7/8 X <br /> Tank Annular#2 X <br /> Tank Annular#3 X <br /> Secondary Pipe Test(Tank Tl:-rul) X <br /> Secondary Pipe Test(Tank T2:-pul) X <br /> Secondary Pipe Test(Tank T3:-diesel) X <br /> STP Containment for Tank Tl:rul-1 X <br /> STP Containment for Tank T2:pul-1 X <br /> STP Containment for Tank T3:diesel-I X <br /> UDC#1/2 X <br /> UDC#3/4 X <br /> UDC#5/6 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 TMS 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: 9/4/2014 <br /> WO:2319172 <br />