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%ftpo S.0 <br /> SWRCB,January 2002 Page I of 5 <br /> Secondary Containment Testing Report Form <br /> This form is intended jbr use by contractors performing periodic testing of UST secondary cwrtainments systems. U.se the appropriate <br /> pages of this form to report results for all components tested. The completed form, written test procedures, and printout from tests(if <br /> applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1.FACILITY INFORMATION <br /> Facility, Pacific Bell Tel hone Co.dba AT&T California Service Date:05113/2010 <br /> Facility,Address: 345 N. SAN JOA UIN STOCKTON CA 95202 GEO PAR#UE042 <br /> Facility Contact:Connie Mitchell Facilit Phone: <br /> Date Local A$ency Was Notified of Testing: 04112712010 Test T : initial <br /> Name of Local Affncy Inspector if present during testing):Jeff Wong,San Joaquin County <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name:Tait Environmental Services <br /> Technician Providing Test : Victor Guerrero <br /> Credentials ®CSLB Licensed Contractor ❑S W RCB Licensed Taak Tester ®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 Tech #8017001-UT 06/16/2011 <br /> Franklin Fueling Incon TS-STS#1621513762 04/13/2011 <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fall Not Repairs Component Paas Fail Not Repairs <br /> Tested Made Tested Made <br /> Annular UE042000I ® ❑ ❑ 11 ❑ <br /> Supply Secondary LJE042U001 ® ❑ ❑ E3 ❑ ❑ ❑ <br /> Return Secondary UE0420001 0 © ❑ ❑ ❑ ❑ <br /> Vent Secondary UE042U001 ® ❑ ❑ F1 ❑ ❑ in El I <br /> Piping Sump UE042U00I ® ❑ ❑ 0 ❑ ❑ ❑ <br /> Middle Sump UE042VO01 ® ❑ ❑ Q ❑ ❑ In <br /> Fill Sump UEC 42Uool Z ❑ ❑ ❑ ❑ 10 <br /> ❑ ❑ ❑ ID ❑ ❑ 10 <br /> ❑ IE1 I❑ I Q ❑ 10 <br /> 11 F-1 17 L00 ❑❑ ❑010 _ ❑ 11IL <br /> If hydrostatic testing was performed,describe what was clone with the water after completion of tests: <br /> All test water was taken back to Tait's shop. <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 infill compliance with legal requirements <br /> Technician's Signature Date 05/13/2010 <br />