Laserfiche WebLink
0 <br />Page of <br />Secondary ContainmentTesting e ort 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. Tire completed form, written test procedures, and <br />printouts from tests (iapplicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />Facility Name: Pacific Bell Telephone Co. dba AT&T California Date of Testing: 8 May 2013 <br />Facility Address: 1812 Coley Ave Escalon, CA. 95320 <br />Facility Contact: Dave Dube I Phone 209 578-7125 ❑ Initial <br />® Repair Test <br />Date Local Agency Was Notified of Testing: 30 April 2013 ❑ 6 Month[]OtherName <br />❑ ICC UST Service Technician <br />of Local Agency Inspector (ifpresent during testing): Thuy Tran ❑ Triennial <br />MIN, M". WKITIJOYS377MI =6, <br />Company Name: service Service Smtbn <br />Technician Conducting Test: Marc Tillotson <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 S . _ _ <br />International Code Council i Int <br />MINIMUM <br />Date Trainin <br />7/19/13 <br />International Code Council twaarviclaTech <br />10/3!14 <br />Incon TS -STS L4 3413033705 <br />5/7/15 <br />3. SUMMARY 1 <br />r + <br />LIM <br />ovvv <br />mum KNA� uuvr� <br />ww=o uuu■� <br />uuvo u��u■� <br />u_noa� uo�ca� <br />ow=v vv <br />uuuu uuu�u� <br />If hydrostatic testmg was performed, describe what was done with the water after completion of tem: <br />Test Trailer was <br />uuu�u■ vuu <br />e. taken .x«. to op <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 RESPONSMLE FOR CONDUCTING THIS TESTING <br />To dlw best of ray knowledge, the facts Mated in this document are accurate and in full compliance with legal re encs <br />Technician's Signature: AMU-, ,ti..,r� Dom; <br />6 May 2013 <br />