Laserfiche WebLink
w <br />SWRCB, January 2002 <br />Secondary Containment Testing Report Form <br />Page 1 of 3 <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 (f <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: R air 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 />It <br />Technician Providing Test: John Cascio <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 />0 NO <br />Manufacturer Training <br />oa <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 />MMMOM <br />3. SUMMARY OF TEST RESULTS <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />Test water returned 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 �,r... Date 01/07/2011 <br />It <br />MM <br />0 NO <br />,. ,, ►_� <br />oa <br />►_, <br />000 <br />voa <br />MMMOM <br />MMMUMM <br />oc■�ar•� <br />oc•�0r•-� <br />oWMFEMaivar•� <br />Woman <br />oomrw <br />ooar•M <br />ooar■u <br />ooa <br />Moa <br />oMMOM <br />MMM0INN <br />nnrmr•m <br />"Ern—IFIErNm <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />Test water returned 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 �,r... Date 01/07/2011 <br />