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SWRCB, January 2002 ENVI U€ IV!,EN ` HEALTHPage 1 of 5 <br />Secondary Containment Testing ReiIrYP- <br />IormI <br />CES <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 (f <br />applicable), should be provided to the facility owner/operatorfor submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility: Pacific Bell Tele hone Co. dba AT&T California <br />Service Date: 08/16/2010 <br />Facility Address: 907 LINCOLN RD. STOCKTON CA 95207 <br />GEO PAR t# UE046 <br />Facility Contact: Connie Mitchell <br />Facili Phone: 209-598-5155 <br />Date Local Agency Was Notified of Testing: 06/29/2010 <br />Test Type: 36 Month <br />Name of Local Agency Inspector if present during testing): None <br />License Type: A B ASB C-10 HAZ <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: Tait Environmental Services <br />Technician Providing Test: LUCK, DAN <br />Credentials IKCSLB Licensed Contractor <br />❑SWRCB Licensed Tank Tester <br />ICC UST Service Technician <br />License Type: A B ASB C-10 HAZ <br />License Number: 588098 <br />Manufacturer Training <br />Manufacturer <br />Component(s) <br />Date Training Expires <br />Franklin Fueling Incon TS -STS <br />2438113761 <br />12/03/2010 <br />ICC Service Tech <br />5252167 -UT <br />09/26/2011 <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />SB989 water was recovered as Non Haz and returned to Tait's Rancho Cordova office, <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my knowledge, the facts stated in thisdocument area <br />urate and ' full compliance with legal requirements <br />Date 08/16/2010 <br />Technician's Signature% j _ •✓ J `/� <br />Annular Tank UE0445UO02 <br />For, <br />WMWE <br />Piping Surnp UF -046L,1002 <br />oo�r:N <br />oa0r:� <br />ooc■�r•� <br />acv©rte <br />c•�ca�c■�r� <br />oc•�r■.�r•� <br />ooc■�n■ <br />oWar:�r <br />r <br />NM <br />M <br />oc�c�r■� <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />SB989 water was recovered as Non Haz and returned to Tait's Rancho Cordova office, <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my knowledge, the facts stated in thisdocument area <br />urate and ' full compliance with legal requirements <br />Date 08/16/2010 <br />Technician's Signature% j _ •✓ J `/� <br />