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!!o KIP/C <br />�. <br />Spill Bucket Testing Report Form <br />This form is intended for use by contractors performing annual testing of UST spill containment structures. The completed form and <br />printouts from tests (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />rwrril "A ii A Tlff%XT <br />1. l+[�`1AJAA1 Al�l'Vdvvaca8 ay.. <br />Facility Name: Verizon Date of Testing: 09/16/2009 <br />Facility Address: 13850 DeVries Road Lodi, CA 95242 <br />Facility Contact: Gary Duvall Phone: 209-985-0843 <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agency Inspector (f present during testing): <br />rATrI- DA4 A Ti(1N <br />Z. 1hnjLj "7 %- A1®ts`1Av—a..= •� - ----- <br />CompanyName: EPIC Compliance Systems, Inc. <br />Technician Conducting Test: Keith Huston <br />Credentials': 0 CSLB Contractor ® ICC Service Tech. ❑ SWRCB Tank Tester Ll(Specify) <br />Other <br />License Number(s): 880430 <br />_ ___...r---T� TAT1r1-enXXA9rlFnN <br />Comments — (include information on repairs made prior to resting, unu r r4,v...... r - <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />I hereby certify that all the information contained in this report is true, accurate, and in full compliance with legal requirements. <br />r� �� •r`�' Date: 09/16/2009 <br />Technician's Signature <br />' State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements <br />may be more stringent. <br />