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Page of 5" <br />Secondary Containment Testing Repoli I 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 comvonents tested- The completed form, written test procedures, and <br />printouts from tests (if appli Conoco Phillips -2705447 loperator for submittal to the local regulatory agency. <br />1469 E HAMMER LN )N <br />Facility Name: STOCKTON, CA 95210 Date of Testing: <br />Facility Address: n05071 -SB989 Testing <br />Facility Contact: Phone: <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agency Inspector (if present during testing): NA <br />2. TESTING CONTRACTOR INFORMATION <br />3. SUMMARY OF TEST RESULTS <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: /I-e!r ---- — -- <br />7 1 4A-4-4-� 41 <br />=lam <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: /I-e!r ---- — -- <br />7 1 4A-4-4-� 41 <br />