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Page —I _of _2_ <br />Secondary Containment Testing Report Form <br />This form is intended for use by contractors performing periodic testing of UST secondary containment s}stems. Use the <br />appropriate pages of this fonn to report results for all components tested. The completed fonn, written test procedures, and <br />printouts from tests (if applicable), should be provided to rhe facility, owner/operator for submittal to the local regulatory agency. <br />FACILITY INFORMATION GFOPAR- CAK4R? CILLC <br />Facility Name: PACBELL DBA AT&T CALIFORNIA Date of Testing: 8/3/07 __ <br />Facility Address: 110 W. TURNER ROAD LODI, CA. Test Type: SB989 <br />Facility Contact: CONNIE MITCHEL Phone (209) 474-4022 ❑ Initial <br />Q Repair Test <br />Date Local Agency Was Notified of Testing: 811/07 © 6 Month <br />®Other <br />Name of Local Agency Inspector (if present during testing): NONE 0 Triennial <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: TAIT ENVIRONMENTAL SERVICES <br />Technician Conducting Test: DAN LUCK <br />Credentials: ® CSLB Licensed Contractor p SWRCB Licensed Tank Tester <br />License Type: A B ASB C-10 HAZ License Number: 588098 <br />Manufacturer Training <br />Manufacturer Component(s) Date Training Expires <br />SUPPLIED UPON REQUEST <br />SUMMARY3. OF RESULTS <br />zm� mm�= <br />wm� um�: m <br />uuuaom mmmm <br />uum� mmmm <br />uum� WW= <br />u M mmmm <br />uuYY mmmm <br />uuu�:a <br />mmmm <br />wwm� mumu■ <br />uuu�:a muu■�:a� <br />uu�a� muuu� <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 <br />of the test report to this certification ❑ System printout attached. <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my knowledge, the facts stated in this documey are accurate and in full compliance with legal requirements <br />Technician's Signaturwl_ t/ _ Date: 8/3/07 <br />