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P .. <br /> Environmental Management P.O.Box 5095 <br /> Room 3E000 <br /> San Ramon,CA 94583 <br /> Secondary Containment Testing Report Form <br /> 1. FACILITY INFORMATION <br /> Facility Name: Pacific Bell Date of Testing: 1/9/03 <br /> Facility Address: 124 W.ELM STREET,LODI <br /> Facility Contact: BOBBIE/KEN MCDONALD Phone: 209-473-5430 <br /> Date Local Agency Was Notified of Testing: 48 HOURS PRIOR(AT LEAST) <br /> Name of Local Agency Inspector Present: NO <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Tait Environmental Systems <br /> Technician Conducting Test: CRAIG BLOCK <br /> Credentials: Z CSLB Licensed Contractor ® SWRCB Licensed Tank Tester <br /> License Type and#: A,B,CIO,HAZ 588098 <br /> Training by Manufacturer <br /> Manufacturer Component(s) Date Training Expires <br /> Supplied Upon Request <br /> 3. SUMMARY OF TEST RESULTS <br /> Number of Tanks Tested: 1 Number of Piping Runs Tested: 1 <br /> Number of Submersible Pump Sumps Tested: 1 Number of UDC Boxes Tested: 0 <br /> Number of Fill Sum s Tested: 1 Number of Overfill Boxes Tested: 0 <br /> Component Pass Fail Comments <br /> ANNULAR Z ❑ <br /> FILL SUMP ® ❑ <br /> PIPE SUMP ® ❑ <br /> SECONDARY PIPE ® ❑ <br /> O ❑ <br /> ❑ ❑ <br /> ❑ ❑ <br /> ❑ ❑ <br /> ❑ ❑ <br /> *All preessu��ree testing must utilize an inert gas. <br /> Technician's Signature: cr—K 0, Date: <br /> R.C.U.S.T.COM <br />