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RECEIVED <br />OCT 202016 <br />SWRCB, January 2002 <br />Secondary Containment Testing Report Fo VIRONMENTAL HEALTH <br />This form is intended for use by contractors performing periodic testing of UST secondary containment syst . P e ENT <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 Fncility TT)- 00010 <br />Client Name: Pacific Bell Telephone Co dba ATT California <br />Date of Testing: 10/3/2016 <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 />El Repair Test <br />Date Local Agency Was Notified of Testing: NA <br />❑ 6 Month <br />❑ Other <br />Name of Local Agency Inspector (f present during testing): None <br />❑ Triennial <br />2. TESTING CONTRACTOR INFORMATION <br />11 Comnanv Name: TAIT Environmental Services 11 <br />Technician Conducting Test: Garrett Warren <br />Credentials: ❑X 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 Trainine <br />Manufacturer Component(s) Date Training Expires <br />Franklin Fueling Incon TS -STS 3754183706 3-25-2017 <br />ICC service Technician 8185019 1-8-2017 <br />V-111 <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />All test water was returned to Tait's 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 />❑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: ial zavwoZ Date: 10/3/2016 <br />M0000OooMPiping/• <br />,, „ <br />Piping..:. <br />oo <br />..Secondary , ,, <br />o�oo�oo�ooo� <br />Secondary,, ,, <br />0000 <br />0000 <br />0000 <br />0000 <br />0000 <br />0000 <br />0000 <br />0000 <br />0000 <br />0000 <br />0000 <br />0000 <br />0000 <br />0000 <br />0000 <br />0000 <br />0000 <br />0000 <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />All test water was returned to Tait's 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 />❑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: ial zavwoZ Date: 10/3/2016 <br />