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MA -09-2011 08:09 Service Station Systems <br />1: 1 1111111a1111111111111 Q + e 1 t <br />408 938 8888 P.03 <br />This form is intendedfor 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. <br />FACILITY INFORMATION <br />Facility Name: SHELIJUSA # 68151 Datc of Tcsting: 4/11/11 <br />Facility Address: 35 N Cherokee Cane — Lodi CA 95240 <br />Facility Contact: I Phonc: (209) 369-152, <br />Date Local Agency Was Notified ofTcsting: 4/4/11 SB999—Repair/Retest <br />Namc of Local Agcncy Inspector (iij'presew during testing): <br />3.S1 ARY OF TEST RESULTS <br />„Component: <br />Tested <br />Made <br />Not <br />Tested <br />,. <br />Made <br />91 Secondary Product <br />EWL R- <br />91 Turbine Sump�ii� <br />�i <br />�s•:.��:.1■■w <br />, <br />MW <br />If hydrostatic tesfing was performed, wasdone with the water after completion of tests: <br />Pump test truck + for <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: gate: 4/11/11 <br />