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,Page 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 />FacilityName: CONOCO PHILLIPS #2705447 <br />1 Date of Testing: 02/22/2008 <br />Facility Address: 1469 E HAMMER LANE STOCKTON, CA, 95209 <br />Facility Contact: MANAGER - TOM <br />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 />Pass <br />Technician Conducting Test: <br />JARROD COOKE <br />Repairs <br />Made Component <br />Credentials: <br />Fail <br />CSLB Licensed Contractor <br />❑ <br />SWRCB Licensed Tank Tester <br />IFR-] <br />License Type: a <br />Manufacturer <br />I License Number: 7 4 316 0 <br />Manufacturer Training <br />Component(s) <br />Date Training Expires <br />tanknology <br />all <br />07/17/2009 <br />❑ <br />❑ <br />Tank Annular 3 UNL <br />X <br />❑ <br />❑ <br />❑ UDC 3/4 <br />x <br />[c�.Yllli I►� /\;�`t17 all Y Df.`711�:� Df.�I1IY1[. <br />Component <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made Component <br />Pass <br />Fail <br />Not <br />Tested <br />Repair <br />Made <br />Tank Annular 4 DIE <br />IFR-] <br />❑ <br />❑ <br />❑ UDC 1/2 <br />El <br />❑ <br />❑ <br />❑ <br />Tank Annular 3 UNL <br />X <br />❑ <br />❑ <br />❑ UDC 3/4 <br />x <br />F. <br />❑ <br />❑ <br />Tank Annular 2 PLU <br />X <br />❑ <br />❑ <br />❑ UDC 5/6 <br />E <br />❑ <br />❑ <br />❑ <br />Tank Annular 1 SUP <br />E <br />❑ <br />❑ <br />o <br />UDC 7/8 <br />El <br />0 <br />❑ <br />❑ <br />Secondary Pipe 4 DIE DIE <br />� <br />1-1 <br />1:1 <br />9/10 <br />1:1 <br />❑ <br />❑ <br />1:1 <br />❑ <br />Secondary Pipe 3 UNL REG <br />❑ <br />F` <br />❑ <br />El <br />❑ <br />❑ <br />❑ <br />❑ <br />Secondary Pipe 2 PLU PLU <br />X <br />❑ <br />❑ <br />x <br />El <br />❑ <br />❑ <br />❑ <br />Secondary Pipe 1 SUP SUP <br />❑ <br />� <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Piping Sump 4 DIEIFTI <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Piping Sump 3 UNL <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Piping Sump 2 PLU <br />Q <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Piping Sump 1 SUP <br />E <br />� <br />El <br />El <br />❑ <br />❑ <br />❑ ::[E] <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />taken water doa <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: 02/22/2008 <br />