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Secondary Containment Testing Report Form <br /> Thisform is intendedfor use by contractors performingperiodic testing of USTsecondary 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 ID: UE020 <br /> Facilit Name: Pacific Bell Tele hone Co. dba AT&T California Date of Testing: 11/21/2014 <br /> Facility Address: 124W. ELM ST.,Lodi,CA 95240 <br /> Facility Contact: Thuy Tran I Phone: (209)474-4022 Initial Repair Test <br /> Date Local Agency Was Notified Of Testing: 10/22/2014 r 6 Month r Other <br /> Name of Local Agency Inspector(if present during testing): None P Triennial <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: Tait Environmental Services <br /> Technician Conducting Test: Victor Guerrero <br /> Credentials: � CSLB Licensed Contractor r SWRCB Licensed Tank Tester rl--' 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 6/11/2015 <br /> Franklin Fueling Incon TS-STS 3581763704 4/21/2015 <br /> 3.SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> Annular UE020U001 F' r I— r r r' r J-'-; <br /> Supply/Return UE020U001 P— r r r `" r <br /> Vent UE020U001 rv— r r r <br /> Piping UE020U001 P r r''; r �, r <br /> Fill UE020U001 F r r r r' — r r <br /> r r r r r r r r <br /> I— r' r r <br /> r r r r r r <br /> r r r r r r r <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> ........ . <br /> IAI1 test water was taken back to Tait's shop. <br /> i <br /> For any equipment capable of generating a printout of test results,you must attach a copy of the test report to this <br /> certification F System printout attached. <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best ofmy knowledge,the facts stated in this documentare accurate and in full compliance with legal requirements <br /> Technician's Signature: ' Date: 11/21/2014 <br /> RECEIVED <br /> DEC 0 8 2014 <br /> ENVIRONMENTAL HEALTH <br />