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UCSB04N—SS#2611194 Page 1 of 7 <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#2611194 1 Date of Testing: 10/22/04 <br /> Facility Address: 2375 TRACY BOULEVARD TRACY, CA <br /> Facility Contact: MANAGER Phone: 209-835-5358 <br /> Date Local Agency Was Notified of Testing: 10/13/04 <br /> Name of Local Agency Inspector(if present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TAIT ENVIRONMENTAL SYSTEMS <br /> Technician Conducting Test: MICHAEL L. STRAWN II <br /> Credentials: ® CSLB Licensed Contractor ❑ SWRCB Licensed Tank Tester <br /> License Type: A B ASB C-10 HAZ License Number: 588098 <br /> Manufacturer Training <br /> Manufacturer Component(s)) Date Training Expires <br /> SUPPLIED UPON REQUEST <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> 87 ANNULAR ® ❑ ❑ ❑ UDC #5-6 ❑ ❑ ❑ 4. <br /> 89 ANNULAR ® ❑ ❑ ❑ UDC #7-8 ❑ ❑ ❑ +�!►: <br /> 91 ANNULAR ® ❑ ❑ ❑ 87 FILL SUMP ❑ ® ❑ <br /> WASTE OIL ANNULAR ® ❑ ❑ ❑ 89 FILL SUMP ❑ ❑ ® ❑ <br /> 87 SECONDARY PIPING ❑ ❑ ® ❑ 91 FILL SUMP ❑ ❑ ® ❑ <br /> 89 SECONDARY PIPING ® ❑ ❑ ❑ WASTE OIL FILL SUMP ❑ ❑ ® ❑ <br /> 91 SECONDARY PIPING ❑ ❑ ® ❑ 87 SPILL BUCKET ❑ ❑ ® ❑ <br /> 87 TURBINE SUMP ❑ ❑ ® ❑ 89 SPILL BUCKET ❑ ❑ ® ❑ <br /> 89 TURBINE SUMP ❑ E ❑ ❑ 91 SPILL BUCKET ❑ ❑ ® ❑ <br /> 91 TURBINE SUMP ❑ ❑ ® ❑ WASTE OIL SPILL BUCKET ❑ ❑ ® ❑ <br /> UDC #1-2 ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> UDC #34 ❑1 0-1 ❑ 1 ❑ 10 ❑ ❑ 1 ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> ALL SB989 TEST WATER USED WAS RE-CONTAINED IN CONTAINER LOCATED IN <br /> TRAILER OF TEST RIG. NO WATER WAS LEFT ON SITE. <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: 10/22/04 <br />