Laserfiche WebLink
Secondary Containment Testing Report Form <br />This form is intended for use by contractors performingperi odic 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 />1. FACILITY INFORMATION Facility ID: UG010 <br />Facilit Name: Pacific Bell Tele hone Co. dba AT&T California <br />Date of Testin : 8/19/2013 <br />Facility Address: 1812 COLEY AVE., Escalon, CA 95320 <br />Not <br />Tested <br />Facility Contact: Bill Keenan <br />Phone: (925) 671-5983 <br />Initial Repair Test <br />Date Local Agency Was Notified Of Testing: 7/23/2013 <br />Name of Local Agency Inspector (if present during testing): NoneTriennial <br />6 Month Other <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: Tait Environmental Services <br />Pass <br />Technician Conducting Test: Dan Luck <br />Not <br />Tested <br />Credentials: CSLB Licensed Contractor r SWRCB Licensed Tank Tester Fv— <br />ICC UST Service Technician <br />License Type: A B ASB C-10 HAZ I License Number: 588098 <br />Not <br />Tested <br />Manufacturer Training <br />Annular UGOIOUOOI <br />Manufacturer <br />Component(s) <br />j-- <br />Date Training Expires <br />ICC Service Tech <br />5252167 <br />r <br />9/29/2013 <br />Franklin Fueling TS STS <br />0639483702 <br />(— <br />11/7/2014 <br />F— <br />F— <br />r <br />r <br />Piping Transition UGOl0U001 <br />f 7 <br />(� <br />3. SUMMARY OF TEST RESULTS <br />Component <br />Pass <br />Fail <br />Not <br />Tested <br />Repairs <br />Made Component <br />Pass <br />Fait <br />Not <br />Tested <br />Repairs <br />Made <br />Annular UGOIOUOOI <br />(v <br />j- <br />j-- <br />r <br />r <br />r <br />Piping/Fill Sump UGOI OU001 <br />F7 <br />(— <br />r <br />F— <br />F— <br />r <br />r <br />Piping Transition UGOl0U001 <br />f 7 <br />(� <br />r <br />r <br />r <br />I r <br />r <br />Vent Transition UGOI OU001 <br />17 <br />r <br />r <br />r <br />r <br />Vent Secondary UG 01 OU001 <br />17 <br />r <br />r <br />Supply Secondary UG010U00I <br />F7 <br />F- <br />F <br />(— <br />Return Secondary UGOI OU001 <br />17 <br />r <br />r <br />r <br />r <br />F- <br />f— <br />r <br />r <br />r <br />r <br />r <br />r <br />r <br />r <br />r <br />r <br />r <br />r <br />r <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />SB 989 test water returned to Tait shop as non/haz. <br />For any equipment capable of generating a print out of test results, you must attach a copy of the test report to this <br />certification r1-00 System printout attached. <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best ofmy knowledge, the facts stated in this document are accurate and in full compliance with legal requirements <br />Technician's Signature:Date: 8/19/2013 <br />