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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/operatorfor submittal to the local regulatory agency. <br /> 1.FACILITY INFORMATION Facility ID: UE020 <br /> Facilit Name: Pacific Bell Tele hone Co. dba AT&T California Date of Testin : 11/30/2011 <br /> Facility Address: 124 W. ELM ST.,Lodi,CA 95240 <br /> Facility Contact: Connie Mitchell I Phone: (209)474-4022 Initial Repair Test <br /> Date Local Agency Was Notified Of Testing: 11/22/2011 6 Month r 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: Dan Luck <br /> Credentials: f CSLB Licensed Contractor SWRCB Licensed Tank Tester FICC UST Service Technician <br /> License Type: A B ASB C-10 HAZ I License Number:588098 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> ICC Service Tech 5252167UT 9/29/2013 <br /> Franklin Fueline TS STS 0639483702 12/1/2012 _ <br /> 3.SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> AnnnularUE020U001 rv—, F' <br /> Fill Sump UE020U001 <br /> Piping Sump UE020U001 (� <br /> Supply/Ret.Sec.UE020U001 F'', F (" r— r �' <br /> Vent Secondary UE020U001 P— r— I— <br /> ( ]" <br /> r <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests <br /> ......._... <br /> SB989 test water returned to Taits 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 <br /> certification System printout attached. <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,the facts stated in this documentare accurate and in full compliance with legal requirements <br /> Technician's Signature: Date: 11/30/2011 <br />