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SWRCB, January 2002 <br />Secondary Containment Testing Report Form <br />Pagel of 5 <br />This form is intended for use by contractors performing periodic testing of UST secondary containments systems. Use 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 Telephone Co. dba AT&T California <br />Service Date: 05/13/2010 <br />Facility Address: 345 N. SAN JOA UIN STOCKTON CA 95202 <br />GEO PAR # UE042 <br />Facility Contact: Connie Mitchell <br />Facility Phone: 209-598-5155 <br />Date Local Agency Was Notified of Testing: 04/27/2010 <br />Test T e: Initial <br />Name of Local Agency Inspector if present during testing): Jeff Wong,San Joaquin <br />County <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: Tait Environmental Services <br />mom <br />Technician Providing Test : Victor Guerrero <br />-020M <br />Credentials ®CSLB Licensed Contractor <br />❑SWRCB Licensed Tank Tester <br />®ICC UST Service Technician <br />License Type: A B ASB C-10 HAZ <br />License Number: 588098 <br />Manufacturer Training <br />Manufacturer <br />Component(s) <br />Date Training Expires <br />ICC UST Service Tech <br />#8017001 -UT <br />06/16/2011 <br />Franklin Fuelinp <br />Incon TS -STS #1621513762 <br />04/13/2011 <br />►_� <br />oar <br />ooa <br />3. SUMMARY OF TEST RESULTS <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 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 in full compliance with legal requirements <br />Technician's Signature. Date 05/13/2010 <br />mom <br />Component <br />-020M <br />Supply #1 dary <br />VEM <br />,Supply #2 Secondary ..,, <br />►_� <br />oar <br />ooa <br />-UE042UOO <br />Piping Sump I <br />aMOM <br />ooa <br />ooa� <br />ooa <br />oaar� <br />vvar■� <br />ooar� <br />ooa <br />ooc.�r•� <br />vaar•� <br />nrnroEr•0 <br />r■nnr.EriM <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 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 in full compliance with legal requirements <br />Technician's Signature. Date 05/13/2010 <br />