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S,WRCB,7anuary 2002 0 Page 1. <br /> Secondary Containment Testing Rep" 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 completedform, written testprocedures, 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 #2705445 Date of Testing: 05/03/2007 <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: CHRISTIAN ELIAS <br /> Credentials: CSLB Licensed Contractor SWRCB Licensed Tank Tester <br /> License Type: License Number: <br /> Manufacturer Traininc <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 UNL FILL El ❑ ❑ 1:1 E D <br /> Spill Box 2 SUP FILL Ifl ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Spill Box 3 DIE FILL ❑ ff] ❑ El ❑ ❑ ❑ ❑ <br /> I Eli El El E L1 L <br /> Q El E <br /> El El El El E <br /> ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ 01 Ell ❑ ❑ <br /> El F-1 El Q El Ej El <br /> El El LJ E Q El El <br /> D 1-1 El El Q Q Ej El <br /> El I El El El EJ <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 /> y9��r�� <br /> Technician's Signature: � lDate: 05/03/2007 <br />