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1 I 4 1 <br />Secon ary Containment Testing Repo orm <br />This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the appropriate pages of <br />this form to report results for all components tested. The completed form, written test procedures, and printouts from tests (if applicable), shoult <br />be provided to the facility owner/operator for submittal to the local regulatory agency. <br />FACILITY INFORMATION CLLC: SKTNCAll GEOPAR: UE -046 <br />Facility Name: SBC <br />Date of Testing: 8/17/05 <br />Facility Address: 907 LINCOLN ROAD <br />STOCKTON, CA <br />Facility Contact: CALVIN MUIR <br />I Phone: 209-943-4128 <br />Date Local Agency Was Notified of Testing: <br />48 HOURS PRIOR <br />Name of Local Agency Inspector (if present during testing): <br />MICHELLE LE <br />2. TESTING CONTRACTOR INFORMATION <br />3. SUMMARY OF TEST RESULTS <br />l .. <br />Component <br />M. <br />1 1 my-TIM•yy... - 1 / l f _®® '1 • 1 <br />• '1 1 <br />MMM <br />mom <br />mommmmmMMMMM <br />mom= <br />ommm <br />mmmmmmmm <br />comma <br />mmmm <br />mom= <br />mmmm <br />ommm <br />mmmm <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />LEFT (1)5 -GALLON PAIL ON SITE <br />To the best of my knowledge, the facts stated in this document are accurate and in full compliance with legal <br />requirements <br />Technician's Signature: <br />Date: 8/17/05 <br />