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RECEIVED <br /> SWRCB,January 2002 <br /> n( 3 0 2017 <br /> Secondary Containment Testing Report Form <br /> This form is intended for use by contractors performing periodic testing of UST secondary contain WW, ._` L HEALTH <br /> appropriate pages of this form to report results for all components tested. The completed form, written test , 'u, <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 Facili ID: UE020 <br /> Client Name: Pacific Bell Telephone Co dba ATT California Date of Testing: 10-17-2017 <br /> Facility Address: 124 W. Elm St. City: Lodi State: CA Zip Code: 95240 <br /> Facility Contact: Thuy Tran Phone: 209-474-4022 ❑ Initial ❑Re air Test <br /> Date Local Agency Was Notified of Testing: 9/24/2017 ❑ 6 Month ❑Other <br /> Name of Local Agency Inspector(if present during testing): None ® Triennial <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TAIT Environmental Services <br /> Technician Conducting Test: Jerry Sanouvong <br /> Credentials: ®CSLB 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 8061056 4-5-18 <br /> Incon TS-STS 1016583708 10-21-17 <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> Annular UE0200001 ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Supply/Return UE0200001 ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Vent UE0200001 ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Piping Sump UE0200001 ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Fill Sump UE0200001 ❑X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <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 /> All test water return to tait shop <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: j" 5"MowDate: 10-17-2017 <br />