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S'WRCB, January 2002 • Page 1 . <br />Secondary Containment Testing Report Form <br />TIT)s fOrn) is Intended for use hl' contractors pe: fOt7ning periodic testing Of t."ST secondan, conta)nnient syste)ns. l'Se the <br />appropriate pages Of this. form to report results f6r all coalpponents tested. The colnpleted forin, Wl•ltten testprocedures-, and <br />printouts from tests (if applicable). should be provided to the facility ou-nerioperator f )r.submittal to the local regulatory agencv. <br />1. FACILITY INFORMATION <br />Facility Name: CONOCO PHILLIPS #2708671 <br />DateofTesting: 03/02/2006 <br />Facility Address: 8606 THORNTON ROAD STOCKTON , CA, 95209 <br />Facility Contact: MANAGER <br />Phone: (2 0 9) 478-8959 <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 />MMER <br />Technician Conducting Test: <br />RHOME DESBIENS <br />Component <br />Credentials: <br />CSLB Licensed Contractor <br />SWRCB Licensed Tank Tester <br />Spill Box 87 <br />License Type: <br />License Number: <br />Manufacturer <br />Manufacturer Training <br />Component(s) <br />Date Training Expires <br />Spill Box 8 9 <br />mm= <br />ME <br />3. SUMMARY OF TEST RESULTS <br />Component <br />MMER <br />M., <br />Component <br />Spill Box 87 <br />Spill Box 8 9 <br />mm= <br />ME <br />If hydrostatic testing was perfonned, 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 rnv knowledge, the fiicts stated in this docunu:nt are accurate and in ftnll compliance with legal requirements <br />Technician's Signature: Date: 03/02/2006 <br />