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11 <br />Ll <br />1 on] *914 VA :1 k <br />1 � i <br />SWRCB, January 2002 Page 1 of 3 <br />Secondary Containment Testing Report For <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 far 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: 01/07/2011 <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: 01/03/2011 <br />Test Type: Repair Test <br />Name of Local Agency Inspector if present during testing): Michelle Henry <br />License Type: A B ASB C-10 HAZ <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: Tait Environmental Services <br />Technician Providing Test : John Cascio <br />�Nr.777 <br />10M <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 />ILicense Number: 588098 <br />Manufacturer Training <br />►Zt ■0� <br />Manufacturer <br />Component(s) <br />Date Training Expires <br />ICC Service Tech <br />5252163 -UT <br />08/30/2013 <br />Franklin Fueling <br />2434733761 <br />02/05/2011 <br />■�r' <br />000x' <br />■000��� <br />3. SUMMARY OF TEST RESULTS <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <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 />T 'a Date 01/07/2011 <br />�Nr.777 <br />10M <br />UE042U001 Fill Sump�� <br />■O�r■� <br />■00����' <br />OO <br />►Zt ■0� <br />►� <br />■DO�r� <br />DD�r' <br />0� <br />■�r' <br />000x' <br />■000��� <br />ooa� <br />aivar� <br />ovatewoa <br />ommrin <br />WnMr■w <br />ooa <br />voar■� <br />oo0a <br />aoar� <br />000 <br />aaaar■� <br />nnr.�r.� <br />nnr•�r•-� <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <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 />T 'a Date 01/07/2011 <br />