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4 <br /> SWRCB,January 2002 <br /> Secondary Containment Testing Report Form <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 procedures, and <br /> printouts from tests (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION Facili ID: UE042 <br /> Client Name: Pacific Bell Telephone Cc dba ATT California Date of Testing: 11/28/2016 <br /> Facility Address: 345 N. San Joaquin City: Stockton State: CA Zip Code: 95202 <br /> Facility Contact: Thuy Tran Phone: (209) 532-3447 ❑ Initial 0 Repair Test <br /> Date Local Agency Was Notified of Testing : 11/8/2016 ❑ 6 Month ❑Other <br /> Name of Local Agency Inspector(fpresent during testing): None ❑ Triennial <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TAIT Environmental Services <br /> Technician Conducting Test: Garrett Warren <br /> Credentials: ❑X CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester ❑X ICC UST Service Technician <br /> License Type: A B ASB C-10 RAZ License Number: 588098 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> Incon TS-STS 375418706 3-25-2017 <br /> ICC Service Tech 8185019 1-8-2017 <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> Fill Sump UE0420001 ❑X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Emergency Return sec UE0420001 ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ I ❑ I ❑ I ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> All test water was returned to Tait's shop. <br /> For any equipment capable of generating a print out of test results,you must attach a copy of the test report to this certification. <br /> 0 System printout attached. <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: 57�f Vavwa Date: 11/28/2016 <br />