Laserfiche WebLink
e <br /> SWRCB,January 2002 Page 1 of 5 <br /> Secondary Containment Testing Report Form <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(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 Service Date:08/04/2009 <br /> Facility Address: 10 E. 12TH ST. TRACY CA 95376 GEO PAR#UE058 <br /> Facility Contact:Connie Mitchell Facility Phone: <br /> Date Local Agency Was Notified of Testing:07/15/2009 Test T e:36 Month <br /> Name of Local Agency Inspector if present during testing):None <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name:Tait Environmental Services <br /> Technician Providing Test:Victor Guerrero <br /> Credentials ®CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester <br /> ®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 06/16/2011 <br /> Franklin Fueling Incon TS-STS 1621513762 04/13/2011 <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 ® ❑ ❑ ❑ ❑ ❑ ❑ <br /> Supply Secondary UE0580002 ® ❑ ❑ El ❑ ❑ ❑ El <br /> Return Secondary UE058UO02 ® ❑ ❑ El ❑ ❑ <br /> Vent Secondary UE058UO02 ® ❑ ❑ El ❑ ❑ ❑ <br /> Fill Sump UE058UO02 ® ❑ ❑ El ❑ ❑ ❑ El <br /> Piping Sump UE058UO02 ® ❑ El El ❑ ❑ <br /> El <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ El <br /> ❑ ❑ ❑ El ❑ ❑ ❑ 01 <br /> ❑ ❑ ❑ ❑ �j ❑ ❑ ❑ <br /> ❑ El 10 1 ❑ ❑ ❑ 0 10 <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> All test water taken from site and returned to Tait's office. <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 Date 08/04/2009 <br />