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SWRCB,January 2002 Page 1 of I <br /> Secondary Containment Testing Report Form <br /> This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the appropriate <br /> pages of this form to report results for all components tested. The completed form, written test procedures,and printouts from tests(if <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:8/30/2013 <br /> Facility Address:3202 W HAMMER LANE ,STOCKTON,CA 95209 <br /> Facility Contact:MANAGER Phone:209-957-2900 <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(if present during testing):garrett <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name:TANKNOLOGY INC. <br /> Technician Conducting Test: Steven Willems <br /> Credentials: W, <br /> 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 secondary containment 9/3/2013 <br /> opw spill bucket 10/16/2013 <br /> 3.SUMMARY OF TEST RESULTS <br /> Not Not Repairs <br /> Component Pass Fail Tested Repairs <br /> Component Pass Fail Tested Made <br /> Tank Annular#1 X <br /> Tank Annular#2 X <br /> Tank Annular#3 X e N <br /> 5 77 77 ' <br /> Secondary Pipe Test(Tank T1:-rul) X � <br /> Secondary Pipe Test(Tank T2:-pul) X <br /> Secondary Pipe Test(Tank T3:-diesel) X <br /> °w Y <br /> Fill Containment for Tank:T 1:rul-1 X s�� <br /> y,�A ��,a zd <br /> Fill Containment for Tank:T2:pul-1 X <br /> Fill Containment for Tank:T3:diesel-I X <br /> Spill Box Tl:rul fill X <br /> Spill Box T2:pul fill X <br /> Spill Box T3:diesel fill X <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> put water back in water wagon and take with me <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS 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: 8/30/2013 <br /> WO:2314059 <br />