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Secondary Containment Testing Report Form <br /> This form is intendedfor use by contractors performingperiodic testing of USTsecondcuycontainment 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/operatorforsubmittal to the local regulatory agency. <br /> 1.FACILITY INFORMATION Facility ID: UE058 <br /> Facili Name: Pacific Bell Tele hone Co. dba AT&T California Date of Testin : 7/10/2012 <br /> Facility Address: 10 E. 12TH ST.,Tracy,CA 95376 <br /> Facility Contact: Connie Mitchell Phone: (209)474-4022 r- Initial rRepair Test <br /> Date Local Agency Was Notified Of Testing: 6/12/2012 r- 6 Month r Other <br /> Name of Local Agency Inspector(if present during testing): None 51-' Triennial <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: Tait Environmental Services <br /> Technician Conducting Test: Victor Guerrero <br /> Credentials: � CSLB Licensed Contractor SWRCB Licensed Tank Tester P- ICC UST Service Technician <br /> License Type: A B ASB C-10 HAZ License Number:588098 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> ICC UST Service Tech. 8017001-UT 6/8/2013 _ <br /> Franklin Fueling INCON TS-STS 3100193701 4/16/2013 _ <br /> 3.SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> Annular UE058UO02 r <br /> Supply Sec. UE058UO02 r r- r- <br /> Return Sec. UE058UO02 rv- r" r- <br /> Vent Sec. UE058UO02 <br /> Fill Sump UE058UO02 P- r-' <br /> Pipe Sump UE058UO02 rv- r', r' r- (� <br /> I- r' f- <br /> f 1_, r- <br /> C` 1 <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 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 <br /> certification r7l System printout attached. <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,the facts stated in this documen tare accurate and in full compliance with legal requirements <br /> Technician's Signature: Date: 7/10/2012 <br />