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Secondary Containment Testing Report Form <br /> This form is intended for use by contractors performingperi odic testing of UST secondary containme nt 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 Facility ID: UE046 <br /> Facilit Name: Pacific Bell Tele hone Co.dba AT&T California Date of Testin : 8/9/2013 <br /> Facility Address: 907 LINCOLN RD.,Stockton, CA 95207 <br /> Facility Contact: Bill Keenan Phone: 209-598-5155 F- Initial F- Repair Test <br /> Date Local Agency Was Notified Of Testing: 7/30/2013 6 Month Other <br /> Name of Local Agency Inspector(if present during testing): NoneTriennial <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: Tait Environmental Services <br /> Technician Conducting Test: Victor Guerrero <br /> Credentials: CSLB Licensed Contractor r- 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 Service Tech. 8017001-UT 6/11/2015 <br /> Franklin Incon TS-STS 3581763704 4/21/2015 <br /> 3.SUMMARY OF TEST RESULTS <br /> Not Repairs Not Repairs <br /> Component Pass Fail Tested Made Component Pass Fail Tested Made <br /> Annular UE046UO02 r- �- r- <br /> Pipe Sump UE046UO02 F F- F <br /> Fill Sump UE046UO02 �- <br /> Supp/Ret UE046UO02 w <br /> r r r- F- <br /> r- r- r <br /> r r- L11 r- r- <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> lAll test water was taken back to Tait's shop. <br /> i <br /> For any equipment capable of generating a print out of test results,you must attach a copy of the test report to this <br /> certification I,--' 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: ,f Date: 8/9/2013 <br />