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,'SWRCB,January 2002 Page 1 of 5 <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: 12/10/2008 <br /> Facility Address: 124 W. ELM ST. LODI CA 95242 GEO PAR#UE020 <br /> Facility Contact:Connie Mitchel Facility Phone: <br /> Date Local Agency Was Notified of Testing: 01/17/2008 Test Type: 36 Month <br /> Name of Local Agency Inspector if present during testing):None <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: Tait Environmental Services <br /> Technician Providing Test:AGUILAR ADOLFO <br /> Credentials MCSLB Licensed Contractor ❑SWRCB Licensed Tank Tester ®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 Technician 5238610-UT 02/24/2009 <br /> Incon TS-STS 2957353761 01/13/2010 <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> Annular#UE020U001 ® ❑ ❑ Q ❑ ❑ ❑ El <br /> Fill Sump #UE020U001 M ❑ ❑ ❑ ❑ ❑ <br /> Piping Sump#UE020U001 M ❑ ❑ ❑ ❑ ❑ <br /> Supply/Return Secondary Line#UE020U001 ® ❑ ❑ 1 El ❑ ❑ ❑ <br /> Vent Secondary Line#UE020U001 ❑ M ❑ Q ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ 0 ❑ ❑ ❑ El <br /> ❑ ❑ ❑ El 10 11 <br /> ❑ ❑ ❑ ❑ ❑ ❑ El <br /> ❑ ❑ ❑ El ❑ ❑ ❑ <br /> I El El 10 Ej El El El El 11 <br /> I L2-LLLL- I a El 11:1 1 <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> Left Three(3)55 Gallon Drums labeled Non-Haz with test water At Site. <br /> CERTIFICATION OF TECHNIC SPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,the facts stated in i doc ent are acc ate and in full compliance with legal requirements <br /> Technician's Signature Date 12/10/2008 <br />