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SWRCB,January 2002 Page 1 of 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 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#32262,MKT 2368(N-3940-1 jDate of Testing: 12/3/2018 <br /> Facility Address:2360 W GRANTLINE I-205 OFF RAMP,TRACY,CA 95376 <br /> Facility Contact:CHANDRA Phone:209-830-9917 <br /> Date Local Agency Was Notified of Testing: 11/21/2018 <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: V 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 4/26/2020 <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> STP Containment for Tank T4 RUL reg unlead- X <br /> I <br /> STP Containment for Tank T5 MUL midgrade-1 x <br /> STP Containment for Tank T6 PUL premium- I X <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> taken water trailer <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,tt hie facts stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: 'Pr— 12/3/2018 <br /> WO:2338566 <br />