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Appendix VII 00010 <br />Underground Storage Tank <br />Secondary Containment Testing Report Form <br />TYPE OF ACTION ❑ Installation ❑ Repair ❑ 6 Month ❑✓ 36 Month <br />1 1. FACILITY INFORMATION <br />CERS ID <br />10181541 <br />Test Date <br />07/11/2022 <br />Facility Name <br />Pacific Bell Telephone Co. dba AT&T California <br />Facility Address <br />1812 Coley Ave. <br />City <br />Escalon <br />ZIP Code <br />95320 <br />2. SERVICE TECHNICIAN INFORMATION <br />Company Performing the Test <br />TAIT Environmental Services, Inc. <br />Phone <br />�(714) 560-8222 <br />Mailing Address <br />11280 Trade Center Dr., Rancho Cordova, CA 95742 <br />Service Technician Performing Test <br />Reggie Velasco <br />Contractor/Tank Tester License Number <br />588098 <br />ICC Number <br />9901046 <br />ICC Expiration Date <br />3/25/2023 <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications <br />Expiration Date <br />FFS EVR Phase I Systems -VR-101 1008293713 <br />02-01-2024 <br />Sump Test System Operation - INCON® Level 4 <br />04-23-2023 <br />4. TEST PROCEDURE INFORMATION <br />Test Procedures Used <br />Components Tested <br />PEI RP 1200 <br />Annular, Supply/Return,Vent secondary, Fill/Piping Sump, Vent Sump, <br />Piping Transition <br />5. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <br />I hereby certify that the secondary containment was tested in accordance with California <br />Code of Regulations, title 23, division 3, chapter 16, section 2637; that required supporting <br />documentation is attached; and all information contained herein is accurate. I understand <br />that test procedures shall be made available upon request by the governing authority. <br />Service Technician Signature <br />~� <br />Date <br />07/11/2022 <br />Total # of Pages <br />CERS = California Environmental Reporting System, ICC = International Code Council, <br />ID = Identification, NA = Not Applicable, UDC = Under -Dispenser Containment, <br />Page 1 of 5 <br />