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SWRCB,January 2002 Page 1. <br /> Second Containment Testing Re t 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 /> FacilityName: CONOCO PHILLIPS #2705447 DateofTesting: 08/06/2007 <br /> Facility Address: 1469 E HAMMER LANE STOCKTON, CA, 95209 <br /> Facility Contact: MANAGER-TOM Phone: (2 0 9) 478-1522 <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: DOUG FALDE <br /> Credentials: ❑ CSLB Licensed Contractor SWRCB Licensed Tank Tester <br /> License Type: ICC License Number: 5307847-UT <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Repairs Not Repair <br /> Component Pass Fail Tested Made Component Pass Fail Tested Made <br /> Spill Box 1 SUP FILL I ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Spill Box 1 SUP VAPOR X ❑ ❑ ❑ ❑ ❑ ❑ El <br /> Spill Box 2 PLU FILL 0 ❑ ❑ El -11F ❑ F-1 ❑ <br /> Spill Box 2 PLU VAPOR ❑ El ❑ ❑ ❑ ❑ <br /> Spill Box 3 UNL FILL ❑ ❑ ❑ <br /> Spill Box 3 UNL VAPOR ❑ ❑ ❑ F-1 F-1 0 <br /> Spill Box 4 DIE FILL D-L-] El ❑ ❑ ❑ ❑ ❑ ❑ <br /> Spill Box 4 DIE VAPOR Ir -'I ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> F1 F1 El El El El <br /> El El F-1 E <br /> ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ 01 ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> RECLAIMED FOR REUSE <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: 08/06/2007 <br />