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9 • Page _of <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 thisform to report results for all components tested. The completed form, written test procedures, and <br />printouts from tests (f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />FACILITY INFORMATION GEOPAR: CAK482 CLLC: LODICA02 <br />Facility Name: AT&T Corp Date of Testing: 1/28/08 <br />Facility Address: 110 W. Turner Road Test Type: SB989 <br />Facility Contact: Connie Mitchell Phone 209-474-4022 ❑ Initial <br />M Repair Test <br />Date Local Agency Was Notified of Testing: 1/24/08 ❑ 6 Month <br />❑Other <br />Name of Local Agency Inspector (fpresent during testing): Ray Von Flue ❑ Triennial <br />Manufacturer TraininE <br />Component(s) Date Training Expires <br />TESTING CONTRACTOR INFORMATION <br />Company Name: TAIT ENVIRONMENTAL SERVICES <br />Technician Conducting Test: <br />Dan Luck <br />Credentials: M CSLB Licensed Contractor ❑ SWRCB Licensed Tank Tester <br />License Type: <br />A B ASB C-10 HAZ License Number: 588098 <br />Manufacturer <br />Manufacturer TraininE <br />Component(s) Date Training Expires <br />ICC <br />UST INSTALLATION/ RETROFITTING 4/10/2009 <br />ICC <br />UST SERVICE TECHNICIAN 9/25/2009 <br />3. SUMMARY OF TEST RESULTS <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />Water Contained in 5 gallon bucket labeled NON-HAZ. Taken from site, back to Sacramento office. <br />For any equipment capable of generating a print out of test results, you must attach a copy <br />of the test report to this certification M 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 fullcompli ce with legal requirements <br />Technician's Signature: �� lG �' Date: / <br />OPW Spill Bucket <br />0000 <br />00�� <br />QQQQ <br />QQ�� <br />0000� <br />QQii'� <br />00�0� <br />QQ��I <br />000 <br />00��! <br />OQOQ <br />is]Q�i� <br />QOQO <br />v0�� <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />Water Contained in 5 gallon bucket labeled NON-HAZ. Taken from site, back to Sacramento office. <br />For any equipment capable of generating a print out of test results, you must attach a copy <br />of the test report to this certification M 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 fullcompli ce with legal requirements <br />Technician's Signature: �� lG �' Date: / <br />