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f SWRCb,January 2002 Page 1. <br /> Secondary Containment Testing Report Form <br /> Thisfiorrn is intended for use by contractors performing periodic testing of UST secondtay containment systems. tlse the <br /> appropriate pages of this form to report results for all components tested. The completed fornt, written test procedures, and <br /> printouts from tests(rf applicable). should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: CONOCO PHILLIPS #2705448 DateofTesting: 03/20/2006 <br /> Facility Address: 3202 W HAMMER LANE STOCKTON, CA, 95209 <br /> Facility Contact: MANAGER Phone: (2 0 9) 957-2900 <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: EICSLB 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 Made <br /> Spill Box 87 a ❑ 1:1 ❑ ❑ El 0 <br /> Spill Box 91 x ❑ Q ❑ ❑ ❑ <br /> Spill Box DSL l X Q1:1E] <br /> 0 1:1 1 DI Q Q ELI <br /> DQ ❑ El M ❑ 0 <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> El F-1 ❑ ❑ El ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑I ❑ D <br /> ❑ ❑ ❑ ❑ Q ❑ ❑ ❑ <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 my knowledge, the facts stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: - Date: 03/20/2006 <br />