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RECEIVED <br /> S WRCB,January 2002 JUN 14 2017 <br /> Secondary Containment Testing Report Form <br /> ENVIR%�,��L HEALTf� <br /> This form is intended for use by contractors performing periodic testing of UST secondary containment sy nl�. <br /> appropriate pages of this form to report results for all components tested. The completed form, written tes c b" <br /> printouts from tests(f applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION Facility ID: PGE095 <br /> Client Name: Pacific Gas and Electric Company Date of Testing: 5-26-2017 <br /> Facility Address: 4040 West Ln. City: Stockton State: CA Zip Code: 95204 <br /> Facility Contact: Alex Steel Phone: ❑ Initial 0 Repair Test <br /> Date Local Agency Was Notified of Testing: None ❑ 6 Month ❑Other <br /> Name of Local Agency Inspector(f present during testing): None ❑ Triennial <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TAIT Environmental Services <br /> Technician Conducting Test: Garrett Warren <br /> Credentials: ❑X CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester 0 ICC UST Service Technician <br /> License Type: A B ASB C-10 HAZ I License Number: 588098 8185019 <br /> Manufacturer Trainine <br /> 7�Manufacturer Component(s) Date Training Expires <br /> Franklin Fueling Incon TS-STS 3754183706 1-9-2019 <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Repairs Not Repairs <br /> Component Pass Fail Cested Made Component Pass Fail ['ested Made <br /> Waste Oil Oil secondary line ❑X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> None <br /> For any equipment capable of generating a print out of test results,you must attach a copy of the test report to this certification. <br /> ❑ System printout attached. <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: o w4vICK Date: 5-26-2017 <br />