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w <br /> SWRCB,January 2002 Page 1 of 2 <br /> Secondary Containment Testing Report Form <br /> This form is intended for use by contractors performing periodic testing of UST secondary containments systems. Use the appropriate <br /> pages of this form to report results for all components tested. The completed form,written test procedures,and printout from tests(if <br /> applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1.FACILITY INFORMATION <br /> Facility:Pacific Bell Telephone Co.dba AT&T California Service Date:03/13/2009 <br /> Facility Address: 124 W.ELM ST. LODI CA 95242 GEO PAR#UE020 <br /> Facility Contact:Connie Mitchell Facility Phone: <br /> Date Local Agency Was Notified of Testing:03/09/2009 Test Type:-Repair Test <br /> Name of Local Agency Inspector if present during testing):M.Naidu <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name:Tait Environmental Services <br /> Technician Providing Test:LUCY,DAN <br /> Credentials ®CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester <br /> ®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 /> INCON 2438113761 12/03/2010 <br /> ICC 5252167-UT 09/25/2009 <br /> 3.SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> Vent Secondary-UE02OU001 ® ❑ ❑ F1 ❑ El <br /> ❑ ❑ ❑ ❑ ❑ ❑ El <br /> ❑ ❑ ❑ El ❑ I❑ ❑ Ej <br /> ❑ IE1 In El I ❑ ❑ ❑ <br /> ❑ I❑ I❑ ❑ ❑ ❑ ❑ <br /> ❑ IE1 10 El I ❑ ❑ ❑ ❑ <br /> ❑ IE1 IF1 El I ❑ ❑ ❑ <br /> ❑ ❑ I❑ El I ❑ ❑ ❑ El <br /> ❑ ❑ 1❑ ❑ ❑ ❑ El <br /> ❑ ❑ ❑ El ❑ ❑ ❑ El <br /> ❑ ❑ I❑ El ❑ ❑ ❑ El <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,the facts stated in this document are accurate d in full compliance with legal requirements <br /> Technician's Signa Date 03/13!2009 <br />