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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 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/operator for submittal to the local regulatory agency. <br /> t. FACILITY INFORMATION GEOPAR:UE046 CLLC:SKTNCA <br /> Facility Name: Pacific Bell Telephone Co.dba AT&T California Date of Testing: 10/11/07 <br /> Facility Address: 907 Lincoln Road, Stockton,Ca Test Type: SB989 <br /> Facility Contact: Connie Mitchell Phone (209)474-4022 ❑Initial ®Repair Test <br /> Date Local Agency Was Notified of Testing: 10/09/07 ❑ 6 Month []Other <br /> Name of Local Agency Inspector(if present during testing): None ❑Triennial <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TAIT ENVIRONMENTAL SERVICES <br /> Technician Conducting Test: S. Graham <br /> Credentials: ® CSLB Licensed Contractor ❑ 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 /> ICC 5240926-UT 6/20/09 <br /> INCON 2768333760 07/06/08 <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> PIPING SUMP# 1171 ® ❑ ❑ <br /> SUPPLY/RETURN SECONDARY ❑ ❑ ❑ <br /> PIPING# 1171 <br /> ❑ ❑ <br /> ❑ ❑ ❑ <br /> ❑ ❑ 0 ❑ ❑ <br /> ❑ 0 n 0 0 ❑ 0 ❑ <br /> ❑ ❑ ❑ <br /> ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> All water left onsite in(4)55 gallon drums <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 document are accurate and in full compliance with legal requirements <br /> Technician's Signature: Date-10/1 1/07 <br />