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Page of --Secondary-Containment-Testing WPOrt FO-rm- This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the l components ted The appropriate pages of this form to l applicaport ble), should be proovidel d to the facility sowner/operator for submittal to the local regulatory agency. printouts from tests( written test procedures,and if app 1. FACILITY INFORMATION Facility Name: Conoco Phillips - #2705445 Date of Testing: Facility Address: 1206 E Match Lane Facility Contact: Phone: _ Stockton, CA. 95207 Date Local Agency Was Notift N041175 — SB989 Testing Name of Local Agency Inspect, _ 2. TESTING CONTRACTOR INFORMATION Company Name: Wayne Perry Inc. Technician Conducting Test: 6 r4 rr1,2!,zu r r G iJ Credentials: ®CSI.B Licensed Contractor ❑SWRCB Licensed Tank Tester License Type: A B ASB C-10 HAZ D40 License Number: 300345 Manufacturer Training Manufacturer Com nent(s) Date Training Expires SUPPLIED UPON REQUEST 3. SUNEWARY OF TEST RESULTS Not Repairs Not Repairs Component Pass Fail Component v, Pass Fail Tested Made Tested Made �b/t,.t L a r � ❑ ❑ ❑ ❑ ❑ ❑ ❑ R of /&se ❑ ❑ ❑ ❑ ❑ ❑ ❑ sf,jeL flit-izsr. Lutes � ❑ ❑ ❑ ❑ ❑ ❑ ❑ % q ¢jt4& DT El El [I ❑ ❑ ❑ ❑ ❑ ❑ ❑ 13 ❑ 1-1 ❑ m ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ v.esce ❑ ❑ ❑ ❑ ❑ ❑ ❑ 0 El El ❑ ❑ ❑ ❑ ❑ ❑ ❑ Ll) C - b gl ❑ ❑ ❑ ❑ ❑ !E] -2 !� ❑ ❑ ❑ ❑ ❑NJ � 9- •c r� 13 11 10:111 C1❑ ❑ [1 ❑ If hydrostatic testing was performed,describe what was done with the water after completion of tests: CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING To the best of my knowledge,the facts stated in this document are accurate and in full compliance with legal requirements Technician's Signature: r &JUa lS Date: Z -,7