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SWRCB,January 2002 JUL 2 0 2016 <br /> Secondary Containment Testing Report Form w y <br /> This form is intended for use by contractors performing periodic testing of UST secondary containment'syst}dN.l Ose" <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 /> 1. FACILITY INFORMATION Facility ID: UE046 <br /> Client Name: Pacific Bell Telephone Co dba ATT California Date of Testing: 7/14/2016 <br /> Facility Address: 907 Lincoln Rd. City: Stockton State: CA Zip Code: 95207 <br /> Facility Contact: Thuy Tran Phone: (209)474-4022 ❑ Initial ❑Repair Test <br /> Date Local Agency Was Notified of Testing: 6/17/2016 ❑ 6 Month ❑Other <br /> Name of Local Agency Inspector(f present during testing): None Triennial <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TAIT Environmental Services <br /> Technician Conducting Test: Victor Guerrero <br /> Credentials: ❑X CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester ❑X 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 /> ICC UST Service Tech. 8017001-UT 6/9/2017 <br /> Franklin Fueling Incon TS-STS 3581763704 4/23/2017 <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> Annular UE0460002 ❑X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Pipe Sump UE0460002 ❑X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Fill Sump UE0460002 0 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Supp/Ret UE0460002 0 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ all ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> All test water was taken back to Tait's shop. <br /> For any equipment capable of generating a print out of test results,you must attach a copy of the test report to this certification. <br /> ❑X 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 te <br /> Technician's Signature: /wm 5�w � Date: 7/14/2016 <br />