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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: CONOCO PHILLIPS #2708671 DateofTesting: 04/11/2007 <br /> Facility Address: 8606 THORNTON ROAD STOCKTON, CA, 95209 <br /> Facility Contact: MANAGER Phone: (2 0 9) 478-8959 <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: CHRISTOPHER SAN NICOLAS <br /> Credentials: 0 CSLB Licensed Contractor 0 SWRCB Licensed Tank Tester <br /> License Type: License Number: <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repair <br /> Tested Made p Tested M <br /> ade <br /> Spill Box 1 PRE FILL E 0 0 0 ❑ ❑ 0 E:1- <br /> Spill <br /> Spill Box 1 PRE VAPOR x ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Spill Box 2 PLU FILL X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Spill Box 2 PLU VAPOR a ❑ ❑ ❑ ❑ ❑ ❑ <br /> Spill Box 3 UNL FILL El ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Spill Box 3 UNL VAPOR E ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 0 0 0 0 0 0 0 0 <br /> 0 0 ❑ 0 ❑ ❑ 0 ❑ <br /> 0 0 0 0 0 0 0 0 <br /> 0 0 0 0 0 0 0 0 <br /> 0 0 0 0 0 0 0 El- <br /> El <br /> 0 0 0 0 0 0 0 <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <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: e /�"'J Date:-04/11/2007 <br />