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SWRCB,January 2002 Page 1. <br /> Secondgy Containment Testing Re ,,rt 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 completed form, written test procedures, 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 /> Facility Name: CONOCO PHILLIPS #2705448 7 DateofTesting: 05/22/2007 <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: DOUG FALDE <br /> Credentials: CSLB Licensed Contractor SWRCB Licensed Tank Tester <br /> License Type: I 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 2 PRE VAPOR Efl ❑ ❑ ❑ ❑ F-1 ❑ EI- <br /> Spill <br /> Spill Box 3 DIE FILL x ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Spill Box 3 DIE VAPOR1:1 ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ F-1 ❑ ❑ ELI <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ I ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ I ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ 1 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> El I ❑ ❑ ❑ 01 ❑ El ❑ <br /> El I ❑ ❑ ❑ El ❑ El ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ El <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <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 /> � 05/22 2007 <br /> Technician's Signature: �-��' -:;2- Date: / <br />