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0 1! <br /> UCSB04N-2611194 Page 1 of 3 <br /> Secondary Containment Testing Report 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 firom 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: CONOCOPHILLIPS#2611194 1 Date of Testing: 12/13/04 <br /> Facility Address: 2375 TRACY BLVD. TRACY, CA 95376 <br /> Facility Contact: MANAGER ON DUTY Phone: 209-835-5358 <br /> Date Local Agency Was Notified of Testing: 12/9/04 <br /> Name of Local Agency Inspector(ifpresent during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TAIT ENVIRONMENTAL SYSTEMS <br /> Technician Conducting Test: MICHAEL L. STRAWN II <br /> Credentials: N CSLB Licensed Contractor ❑ SWRCB Licensed Tank Tester <br /> License Type: A B ASB C-10 HAZ License Number: 588098 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> SUPPLIED UPON REQUEST <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> 87 SECONDARY PIPING ® ❑ ❑ ❑ u" ❑ ❑ ❑ ❑ <br /> 91 SECONDARY PIPING ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 87 TURBINE SUMP ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 91 TURBINE SUMP ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ 1 ❑ 1 ❑ ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> ALL SB989 TEST FLUID WAS RE-CONTAINED IN (4) D.O.T. APPROVED 55-GALLON DRUMS <br /> WHICH WERE HAZMAT LABELED FOR FUTURE TRANSPORT. NO TEST FLUID WAS <br /> TAKEN FROM SITE. <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: 12/13/04 <br />