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SWRCB,January 2002 DEC 1 ; 2016 <br /> Secondary Containment Testing Report Form ENVIRONMENTAL HEALTH <br /> Report PERMITISERVICES <br /> This form is intended fof•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. FACILITY INFORMATION Facility ID: PGE095 <br /> Client Name: Pacific Gas and Electric Company Date of Testing: 11/22/2016 <br /> Facility Address: 4040 West Ln. City: Stockton State: CA Zip Code: 95204 <br /> Facility Contact: Alex Steele Phone: 209-337-8902 ❑ Initial I❑Repair Test <br /> Date Local Agency Was Notified of Testing: 11/08/2016 ❑ 6 Month ❑Other <br /> Name of Local Agency Inspector(f present during testing): None ❑X Triennial <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Compan} Name: TAIT Environmental Services <br /> Technician Conducting Test: Jerry Sanouvong <br /> Credentials: ❑X CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester ❑X ICC UST Service Technician <br /> License Type: A B ASB C-10 HAZ License Number: 588098 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> ICC 8061056 4/5/2018 <br /> Incon level 4 1016583708 10/21/2017 <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> Unleaded Sump ❑X ❑ ❑ ❑ Unleaded 2 UDC ❑X ❑ ❑ ❑ <br /> Unleaded Secondary ❑X ❑ ❑ ❑ Diesel UDC ❑X ❑ ❑ ❑ <br /> Unleaded Annular ❑X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Diesel Sump ❑X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Diesel Secondary ❑X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Diesel Annular ❑R ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Vent Sump ❑R ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Waste Oil Sump ❑X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Waste Oil Secondary ❑X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Waste Oil Vent Q ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Waste Oil Annular ❑X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Unleaded 1 UDC ❑X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> All test water was left on site <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: f6u, 5"46i" Date: 11/22/2016 <br />