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SWRCB, January 2002 <br />JUL 2 9 2016 <br />Secondary Containment Testing Report Form"nor% r; <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 (f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1. FACII.ITV INFORMATION Farilrtv In. 00010 <br />Client Name: Pacific Bell Telephone Co dba ATT California <br />Date of Testing: 7/19/2016 <br />Facility Address: 1812 Coley Ave. City: Escalon <br />State: CA Zip Code: 95320 <br />Facility Contact: Thuy Tran Phone: (209) 474-4022 <br />❑ Initial <br />❑ Repair Test <br />Date Local Agency Was Notified of Testing : 6/28/2016 <br />❑ 6 Month <br />❑ Other <br />Name of Local Agency Inspector (f present during testing): None <br />Triennial <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: TAIT Environmental Services <br />Technician Conducting Test: John Cascio <br />Credentials: 0 CSLB Licensed Contractor ❑ SWRCB Licensed Tank Tester ❑X ICC UST Service Technician <br />License Type: A B ASB C-10 HAZ I License Number: 588098 <br />Manufacturer Training <br />Manufacturer Component(s)) Date Training Ex ires <br />ICC Service Tech 5252163 -UT 09-14-2017 <br />Franklin Fueling TS -STS 6929323704 11-05-2016 <br />01 ILVA FAI MTKII M N SIMM-5-01rim <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <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 />❑X 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: <br />Date: 7/19/2016 <br />mw� <br />��� <br />M, <br />' 1,111111111 <br />fflifm� <br />mom <br />• • • 1 / 11 <br />mom <br />mmm� <br />...Transition:. 1111 <br />MWE <br />oaoo <br />Vent Transition Box UG01OU001ammm <br />mmm� <br />Vent Secondary U1 1 1 / <br />�mmm <br />MMMM <br />,Supply- . .. 1 1 11 <br />mom <br />ffm� <br />Return Secondary U1 1 11 <br />offilmm <br />0000 <br />0000.. <br />0000 <br />0000... <br />0000 <br />0000 <br />0000 <br />0000 <br />0000 <br />_ -- <br />0000 <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <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 />❑X 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: <br />Date: 7/19/2016 <br />