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SWRCB, January 2002 <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 Facili y ID : UE058 <br /> Client Name : Pacific Bell Telephone Co dba ATT California Date of Testing : 5/31 /2018 <br /> Facility Address : 10 E . 12th St. City : Tracy State : CA Zip Code : 95376 <br /> Facility Contact: Thuy Tran Phone: (209) 532-3447 ❑ Initial ❑ Repair Test <br /> Date Local Agency Was Notified of Testing : 5/ 15/2018 ❑ 6 Month ❑ Other <br /> Name of Local Agency Inspector (if present during testing) : None Triennial <br /> 2 . TESTING CONTRACTOR INFORMATION <br /> Company Name : TAIT Environmental Services <br /> Technician Conducting Test: Jarrett Flewellyn <br /> Credentials : ❑X CSLB Licensed Contractor ❑ SWRCB Licensed Tank Tester ❑X 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 UST Service Technician 8028164 03-23-2019 <br /> Franklin Fueling TS-STS 1032363709 09-29-2019 <br /> 3 . SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> Annular UE580002 MX ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Supply Secondary UE0580002 QX ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Return Secondary UE0580002 ❑X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Vent Secondary UE0580002 Q ❑ ❑ ❑ ey^ ❑ ❑ ❑ ❑ <br /> Pipe Sump UE0580002 191 ❑ ❑ ❑ ❑ ❑ ❑ <br /> Fill Sump UE0580002 0 ❑ ❑ ❑ ❑ ❑ p ❑ <br /> ❑ Feel El El Ar <br /> t ❑ ❑ ❑ <br /> ❑ Fel ED ❑ `%'' ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ e ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ Feel <br /> El 11 1:11:1J N ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed, describe what was done with the water after completion of tests : <br /> All test water was taken back to the TAIT 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: P"ea 57& ` &" Date: 5/31 /2018 <br />