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SWRCB, January 2002 <br />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 #2705446 <br />DateofTesting: 04/23/2008 <br />Facility Address: 1403 COUNTRY CLUB BLVD , STOCKTON, CA, 95204 <br />Facility Contact: MANAGER <br />Phone: (2 0 9) 943-2082 <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: DANIEL ORTIZ <br />Credentials: <br />Spill:. - <br />CSLB Licensed Contractor <br />SWRCB Licensed Tank Tester <br />00 <br />License Type: <br />Manufacturer <br />License Number: <br />Manufacturer Training <br />Component(s) <br />Date Training Expires <br />�--� � � <br />0000:: <br />oo <br />■ <br />o <br />Spill =- ■��0000�■■��■■■�0000 <br />K� U�h7 �iI 11 FYI 11.7x.Y11 N K <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: �� nA Date: 04/23/2008 <br />Spill:. - <br />0000 <br />00 <br />0 <br />�--� � � <br />0000:: <br />oo <br />■ <br />o <br />Spill =- ■��0000�■■��■■■�0000 <br />� <br />0000 <br />0000: <br />0000 <br />0000 <br />■��0000 <br />0000 <br />■ <br />0000 <br />0000 <br />■■�0000� <br />0000 <br />0000 <br />■0000 <br />■AWMI <br />0000 <br />0000 <br />0000 <br />0000 <br />�■■��0000 <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: �� nA Date: 04/23/2008 <br />