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Page 1 of 8 <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 appropriate pages of <br />this form to report results for all components tested. The completed form, written test procedures, and printouts from tests (if applicable), should <br />be provided to the facility ownedoperator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: Verizon <br />I Date of Testing: 09-13-2010 <br />Facility Address: 13850 Devries Road <br />Lodi, CA 95242 <br />Facility Contact: Jonathan Pakele Phone: 209-235-3670 <br />Date Local Agency Was Notified of Testing : <br />9-9-2010 <br />Name of Local Agency Inspector (Ypresent during testing): <br />Aris Cacapit <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: EPIC Compliance Systems <br />Technician Conducting Test: Al Milburn <br />Credentials: ❑ CSLB Licensed Contractor RI SWRCB Licensed Tank Tester <br />License Type: License Number: 90-1409 <br />Manufacturer Training <br />Manufacturer Component(s) Date Training Expires <br />3. SUMMARY OF TEST RESULTS <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <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 <br />Technician's Signature: Date: 09-13-2010 <br />COMER <br />no= <br />` <br />0000 <br />QQQQ <br />Secondary FOS <br />0000 <br />QQQQ <br />- . .. • • <br />OQQQ <br />QQQQ <br />Spill Bucket <br />0000 <br />QQQQ' <br />• <br />QQQ� <br />QQQQ <br />QQQQi <br />QQQQ <br />01 ' <br />QQQQ <br />QQQQ'' <br />0000 <br />0000, <br />OOOOI <br />0000 <br />0000 <br />0000' <br />0000 <br />0000 <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <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 <br />Technician's Signature: Date: 09-13-2010 <br />