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SWRC13,January 2002 Page 1. <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 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 #2705446 DateofTesting: 05/19/2008 <br /> Facility Address: 1403 COUNTRY CLUB BLVD , STOCKTON, CA, 95204 <br /> Facility Contact: MANAGER Phone: (2 0 9) 943-2 082 <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(if present during testing): RAY VON FLUE <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TANKNOLOGY, INC. <br /> Technician Conducting Test: KRISTOPHER BELL <br /> Credentials: CSLB Licensed Contractor SWRCB Licensed Tank Tester <br /> License Type: License Number: 5297793-UT <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> OPW INSTALATION <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 3 SUP FILL ❑ El ❑ ❑ El F] <br /> Spill Box 1 DIE FILL 0 ❑ ❑ ❑ ❑ <br /> El F-1 El El E <br /> ❑ E ❑ ❑ ❑ ❑ ❑ <br /> El El F-1 Ell Eli El El <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> TOOK WATER WITH ME <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: .1-21, 1 �� Date: 05/19/2008 <br />