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t <br /> 0 <br /> SWRCB,January 2002 Page_I_of_1_ <br /> Secondary Containment Testing Report Form <br /> This form is intended for 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 CLLC: SKTNCA01 GEO PAR: UG-042 <br /> Facility Name: AT&T/SBC I Date of Testing: 8/21/06 <br /> Facility Address: 345 N.SAN JOAQUIN,STOCKTON <br /> Facility Contact: CONNIE MITCHELL Phone: 209-474-4022 <br /> Date Local Agency Was Notified of Testing: 48 Hours Prior–At Least <br /> Name of Local Agency Inspector(if present during testing): None <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Tait Environmental Systems <br /> Technician Conducting Test: MICHAEL L.STRAWN,II <br /> Credentials: ®CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester <br /> License Type: A ASB HAZ B C-10 License Number: 588-098 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date TrainigE Expires <br /> SUPPLIED UPON REQUEST <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> ANNULAR <br /> SUPPLY SECONDARY PIPING <br /> RETURN SECONDARY PIPING <br /> VENT SECONDARY PIPING <br /> PIPING SUMP <br /> "MIDDLE" TANK SUMP <br /> FILL SUMP <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> *All Hydrostatic Test water was re-contained in(5) 55 gallon poly drums. <br /> All drums are labeled non-haz and are ready for transport. No drums were <br /> removed from site by testing contractor. <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,the facts stated i tthis document.are accurate and in full compliance with legal requirements <br /> Technician's Signatu Date:-8/21/06 <br />