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alw��M <br />This Secondary Containment Testing Report Form-(SB989) <br />fiorm is intendedfor use by contractors performing periodic testing of UST secondary containment systems. Usethe <br />appropriate pages ofthisform to report resultsfor all components tested The completedform, written test procedures, and <br />Printoutsfrom tests (if applicable), should be provided to thefacility ownerloperatorfor submittal to the local regulatory agency, <br />Facility Name: Mobile Tesoro Date of Testing: 4/14/2017 <br />ility Address: 401 W Kettlemen Lane, Lodi, CA 95240 <br />;Fac:ility Contact: Elizabeth OkupI Phone: (209) 368-8787 <br />Date Local Agency Was Notified of Testing <br />Name of Local Agency Inspector (ii(present during testing): Aaron <br />FAT72 r-TTMEMPRE. TV I E%q M. " <br />3 4;.'ITMX4A]DV Ar q -r <br />Component <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />Component <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />87 STP <br />0 <br />91 STP <br />❑❑❑❑❑❑0 <br />87 ANN <br />91 ANN SPACE <br />87 SEC <br />CEJ <br />El <br />El <br />0 <br />0 <br />91 SEC <br />El <br />0 <br />❑0 <br />UDC 1/2 <br />R <br />0 <br />0 <br />0 <br />0 <br />UDC 3/4 <br />El <br />rl <br />❑ <br />0 <br />El <br />0 <br />0 <br />0 <br />❑ <br />01 <br />El <br />0 <br />0 <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />Taken and diciposed as hazardous waste <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To lite best of my knowledge, the facts stated in this document are accurate and in full compliance with legal requirements <br />