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Second 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 />1 this form to report results for all components tested. The completed form, written test procedures, and printouts from tests (if applicable), <br />should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />I, FACILITY INFORMATION CLLC: SKTNCAII GEO PAR: UE -046 <br />Facility Name: SBC Date of Testing: 8/6/04 <br />Facility Address: 907 LINCOLN ROAD <br />Facility Contact: KATHY HALLIGAN <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agency Inspector (f present du) <br />STOCKTON,CA <br />Phone: 209-474-4514 <br />48 HOURS PRIOR <br />testing): <br />2. TESTING CONTRACTOR INFORMATION <br />3. SUMMARY OF TEST RESULTS <br />Not Repairs Not Repairs <br />Component Pass Fail Tested Made Component Pass Fail Tested Made <br />DIESEL FILL <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <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:./LtA..�� <br />�-,t, ,.1, Date: 8/6/04 <br />