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SWRCB,January 2002 Page 1. <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 <br /> appropriate pages of this form to report results for all components tested. The completed form, written test procedures, and <br /> printouts from tests(if 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 #20632, MKT 2368 DateofTesting: 10/14/2009 <br /> Facility Address: 4627 DA VINCI DR @ MARCH LN, STOCKTON, CA, 95207 <br /> Facility Contact: MGR - SATBIR (PTO# N-748) Phone: (2 09) 952-3 543 <br /> Date Local Agency Was Notified of Testing: / / <br /> Name of Local Agency Inspector(if present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TANKNOLOGY, INC. <br /> Technician Conducting Test: JARROD COOKE <br /> Credentials: CSLB Licensed Contractor SWRCB Licensed Tank Tester <br /> License Type: a I License Number: 743160 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> tanknology all 07/18/2011 <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Repairs Not Repair <br /> Component Pass Fail Tested Made Component Pass Fail Tested Made <br /> Tank Annular 1 REG Fx I ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Tank Annular 2 PRE x ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Secondary Pipe 1 REG REG ❑ FRI ❑ El El ❑ El ❑ <br /> Secondary Pipe 2 PRE SUP x ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Piping Sump 2 PRE ❑ F--1 ❑ ❑ ❑ ❑ ❑ ❑ <br /> Piping Sump 1 REG 1:1 ❑ El <br /> El ❑ <br /> UDC 1/2 El ❑ ❑ ❑ El ❑ ❑ ❑ <br /> UDC 3/4 El 1:1 ❑ ❑ 1:1 ❑ ❑ ❑ <br /> El El F-1 El F-1 El <br /> El El El ❑ ❑ F� El <br /> El- <br /> El F1 El El El F-1 El E <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> taken water dog <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: 10/14/2009 <br />