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SWRCB, January 2002 <br />Page 1. <br />Secondary Containment Testing Report Form <br />This ,forni is intended for use by cora�t7'actors performing periodic testing of UST secondary containment systems. Use the <br />appropriate pages of this form to report resultsfor all coinponents tested. The completed form, written test procedures, and <br />printouts from tc sts (f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />I=Intl i ffl aldn" 1311101 Mus] <br />Facility Name: CONOCO PHILLIPS #2705447 <br />Date of Testing: 07/2 1/2 006 <br />Facility Address: 1469 E HAMMER LANE STOCKTON, CA, 95209 <br />Facility Contact: MANAGER <br />Phone: (2 0 9) 478-1522 <br />Date Local Agency Was Notified of Testing <br />Name of Local Agency .Inspector (if present during testing): <br />Company Name: TANKNOLOGY, INC. <br />Technician Conducting Test: <br />RAYMOND SIMMS <br />Component <br />M <br />Credentials: <br />❑ <br />CSLB Licensed Contractor <br />❑ <br />SWRCB Licensed Tank Tester <br />License Type: <br />Manufacturer <br />License Number: <br />Manufacturer Training <br />Components} <br />Date Training Expires <br />Spill Box 87 <br />Spill Box 89 <br />.%1v4- 1 <br />Component <br />EDWIN <br />Component <br />M <br />IN] <br />Spill Box 87 <br />Spill Box 87 <br />Spill Box 89 <br />Spill Box 89 <br />Spill Box 91 <br />Spill Box 91 <br />Spill Box dsl <br />MWE um <br />If hvdrostatic testing tilos 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 nay knowledge, the f acts stated in this document are accurate and in All compliance with legal requirements <br />Technician's Signature:__ �_ Date: 07/21/2006 <br />