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1 0 0 <br />SWRCB, January 2002 Page 1 of 1 <br />Secondary Containment Testing Report Form JFw <br />Thisform is intendedfor use by contractors performing periodic testing of UST secondary containmentfs" <br />QUVrD <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. 1 0 7 2014 <br />1. FACILITY INFORMATION r°& tY #1 K I IA Nr® 1 A 1 <br />Facility Name: 7 ELEVEN 35355 jDate of Testing: 2/18/2014 <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): not presant <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: TANKNOLOGY INC. <br />Technician Conducting Test: Jarrod Cooke <br />Credentials: W 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 5/16/2014 <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 />UDC # 1/2 <br />X <br />UDC # 3/4 <br />X <br />UDC # 5/6 <br />X <br />UDC # 7/8 <br />X <br />Fill Containment for Tank: T1: rul - 1 <br />X <br />Fill Containment for Tank: T2: put - 1 <br />X <br />Fill Containment for Tank: T3: diesel - 1 <br />X <br />Spill Box Tl: rul fill <br />X <br />Spill Box Tl: rul vapor <br />X <br />Spill Box T2: pul fill <br />X <br />Spill Box T2: pul vapor <br />X <br />Spill Box T3: diesel fill <br />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 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: 2/18/2014 <br />WO: 2316238 <br />