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0 0 <br />Secondary Containment Testing Report Form RECEIVED <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 proce <br />printouts from tests (if applicable), should be provided to thefacilityowner/operatorforsubmittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility ID: UE042 MURCMEML iEPj-TH <br />Facilit Name: Pacific Bell Tele hone Co. dba AT&T California <br />Date of Testin . 3/3/ <br />Technician Conducting Test: Victor Guerrero <br />Facility Address: 345 N. SAN JOAQUIN, Stockton, CA 95202 <br />Credentials: �' CSLB Licensed Contractor SWRCB Licensed Tank Tester <br />ICC UST Service Technician <br />Facility Contact: Dave Dube <br />Phone: 209-598-5155 <br />Initial <br />Repair Test <br />Date Local Agency Was Notified Of Testing: 2/14/2014 <br />F- 6 Month <br />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 />Fail <br />Technician Conducting Test: Victor Guerrero <br />Repairs Component <br />Made <br />Credentials: �' CSLB Licensed Contractor SWRCB Licensed Tank Tester <br />ICC UST Service Technician <br />License Type: A B ASB C-10 HAZ <br />License Number: 588098 <br />Vent UE042UO01 <br />Manufacturer Training <br />Manufacturer Component(s) <br />Date Training Expires <br />ICC UST Service Tech. 8017001 -UT <br />6/11/2015 <br />Franklin Fueling Incon TS -STS 3581763704 <br />4/21/2015 _ <br />3. SUMMARY OF TEST RESULTS <br />Component Pass <br />Fail <br />Not <br />Tested <br />Repairs Component <br />Made <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made <br />Vent UE042UO01 <br />F <br />r- <br />r <br />r <br />F <br />r- <br />F <br />F <br />r <br />r - <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <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 r- 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: , f e -IN Date: 3/3/2014 <br />