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0 0 RECEIVE <br />SWRCB, January 2002 Pagel of 5 <br />ENVMNME'NTAL HEALTH <br />Secondary Containment Testing Report Form PERMMSERVICES <br />This form is intended for use by contractors performing periodic testing of UST secpndary 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: 10/25/2010 <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: 10/18/2010 <br />Test Type: 6 Month <br />Name of Local Agency Inspector if present during testing): None <br />License Type: A B ASB C-10 HAZ <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: Tait Environmental Services <br />®® <br />� <br />Technician Providing Test: Victor Guerrero <br />.-001019M <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 />I License Number: 588098 <br />MMMUM <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 Fueling Incon TS -STS <br />#1621513762 <br />04/13/2011 <br />3. SUMMARY OF TEST RESULTS <br />�'Component <br />®® <br />� <br />.-001019M <br />►5 <br />Omffi' <br />MMMUM <br />SecondaryM0 <br />■Mr'■OOMrE—M <br />,Supply #2 Secondary UE042UOO I <br />NM <br />ri—M <br />NN <br />MOM <br />'Piping Sump . <br />►-� <br />aar•-� <br />aoar•� <br />Widle Sump <br />►_� <br />00MM <br />avar� <br />M1►:� <br />ar•M <br />ooaINN <br />oMM <br />MM— <br />c■ <br />MM <br />E <br />c■MM <br />r•= <br />ooarrm <br />r■ar <br />MMu <br />oomr•m— <br />ooar■m <br />amara <br />MR <br />"E <br />rnmr.m <br />rnn <br />MEM <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 Taits 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 10/25/2010 <br />