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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 system,s. Use the <br /> appropriate pages of this forst to report results for all components tested. The completed fora, written test procedures, and <br /> printouts front tests(]f applicable), .should be provided to the facilhy owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: CONOCO PHILLIPS #2705445 Dateof Testing: 05/05/2006 <br /> Facility Address: 1206 E MARCH LANE STOCKTON, CA, 95210 <br /> Facility Contact: MANAGER Phone: (209) 478-6487 <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: RAYMOND SIMMS <br /> Credentials: ❑CSLB Licensed Contractor ❑ 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 /> Not Repairs Not Repair <br /> Component Pass Fail Tested Made Component Pass Fail Tested <br /> Made <br /> Spill Box 1 ❑K ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Spill Box 1 ❑K ❑ El ❑ ❑ ❑ ❑ ❑ <br /> Spill Box 2 ❑K ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Spill Box 2 ❑x ❑ ❑ ❑ ❑ ❑ ❑ rEE1 Spill Box 3 ❑X El El El ❑ ❑ ❑ <br /> ❑ F-1 El El ❑ ❑ El <br /> ❑ ❑ El Ell 01 El <br /> ❑ ❑ ElEl ❑ ❑ ❑❑ ❑ ❑ ❑ ❑ ❑ El <br /> t <br /> LE ❑ ❑ ❑ ❑❑ ❑ ❑ ❑❑ ❑ ❑ ❑ ❑ <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 faacis stated in this document are accurate and in Jull compliance with legal requirements <br /> Technician's Signature:_ Date: 05/05/2006 <br />