Laserfiche WebLink
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: 09/17/07 <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: 08/24/07 ❑ 6 Month [-]Other <br /> Name of Local Agency Inspector(if present during testing): None Z Triennial <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TAIT ENVIRONMENTAL SERVICES <br /> Technician Conducting Test: MICHAEL STRAWN <br /> Credentials: Z CSLB Licensed Contractor ❑ SWRCB Licensed Tank Tester <br /> License Type: A B ASB C-10 HAZ License Number: 588098 <br /> 3 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> ICC 5262091-UT 09/22/07 <br /> INCON 755803761 01/25/07 <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> ANNULAR TANK# 1171 Z ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> PIPING SUMP# 1171 ❑ Z ❑ ❑ ❑ ❑ ❑ ❑ <br /> FILL SUMP#1171 Z ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> SUPPLY/RETURN SECONDARY ❑ Z ❑ ❑ ❑ ❑ ❑ ❑ <br /> PIPING# 1171 <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> ALL HYDROSTATIC TEST WATER NON RECONTAINED IN(4)55 GALLON POLY DRUMS <br /> ALL DRUMS ARE LABELED AS NON-HAZ AND WERE NOT REMOVED FROM SITE. <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 Z System printout attached. <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,the facts stated in th' decument are accurate and in full compliance with legal requirements <br /> Technician's Signature: — Date 09/17/07 <br />