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-: <br /> npv <br /> UL 0 9 2008 <br /> SWRCB,January 2002 <br /> Secondary Containment Testing Report Form" ,`'A}` <br /> EIR /SIR\1'—ES <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:AT&T Corporation Service Date:06/23/2008 <br /> Facility Address:J110 W.Turner Rd. Lodi CA 95242 GEO PAR#CAK482 <br /> Facility Contact:CONNIE MITCHELL E.S.M. Facili Phone: <br /> Date Local A ency Was Notified of Testing:05/19/2008 Test Type:36 Month <br /> Name of Local Agency Inspector if present during testing): SAN JOA UIN COUNTY ENVIRONMENTAL HAEALTH <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name:Tait Environmental Systems <br /> Technician Providing Test:STRAWN MICHAEL 200,399 <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 /> I.C.C. #5262091-UT 09/22/2009 <br /> FRANKLIN FUELING ICON #755803761 01/25/2009 <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> ANNULAR#CAK482U001 ® ❑ ❑ El ❑ <br /> SUPPLY SECONDARY#CAK482U001 ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> RETURN SECONDARY#CAK482U001 ® ❑ ❑ El ❑ ❑ ❑ ❑ <br /> SUPPLY SUMP(NORTH)#CAK482U001 ® ❑ ❑ ❑ ❑ ❑ ❑ Ej <br /> RETURN SUMP(SOUTH)#CAK482U001 ® ❑ ❑ El ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ Ll <br /> ❑ ❑ ❑ L1 ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ El ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ 1❑ 10 ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> ALL HYDROSTATIC TEST WATER WAS RECONTAINED IN(5)55 GALLON POLY DRUMS.ALL DRUMS WERE <br /> LABELED AS NON-HAZ AND REMAIN ON SITE FOR TRANSPORT. <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,the facts stated in thi a cygategiul in full compliance with legal requirements <br /> Technician's Signature Date 06/23/2008 <br />