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DEC -05-2008 12:23 <br />Service Station Systems <br />408 938 8888 P.03 <br />Secondary Containment Testing Report Form <br />This form is intended for use by contractors perforating 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 />I- FAMT.TTV TWIM ATION <br />Facility Name: USA Gas #68iSi Date of Tasting: 9/ AM <br />Facility Address: 35 N. Cherokee Lane — " CA 95240 <br />Facility Contact: I Phone: <br />Date Local Agency Was Notified of Tcsting : SR989 — Rudcet Install — Post Test <br />Name of Local Agency Inspector (if present during testing): <br />3. SLWMARY OF TES RESULTS <br />Not iip�am <br />Component: <br />Tested Ma <br />89 Fill Bucket <br />M M' <br />0if hydrostatic tating was MformecL ckscribe what wa3 done witb the water after completion of tests: <br />��i��� <br />CERTIMCATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my knowledge, dw facts stated in this document are accurate and in full oorapliunce with legal requirements <br />Technician's Signanue: _ _ Date;: <br />