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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 ownerloperatorfor submittal to the local regulatory agency. <br />1. FACILITY INF® TION <br />I Date of Testing: UV/ 10/ ZuUV <br />Facility Name: Verizon <br />Facility Address: 13850 DeVries Road Lodi, CA 95242 1 Phone: 209-985-0843 <br />Facility Contact: Ga !Y Duvall <br />Date Local Agency was Notified of Testing: <br />Name of Local Agency Inspector (irpresent during testing): <br />2. TESTING CONTRACTOR INFORMATION <br />Com an Name: [C Compliance SystemsInc. <br />Technician Conducting Test: Keith Huston <br />-E;We-ntials. 0 CSLB Contractor 0 ICC Service Tech. L3 SWRCB Tank Tester 0 other (Specify) <br />License Number(s): 880430 <br />Comments — include in ormadion on re airs madeDrior to murix, g4r," r — ...... — --- -- - -- <br />CERTIFICATION OF TEcon <br />CHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />I hereby certify that all the information contained in this report is true, accurate, and in full compliances <br />legal requirement <br />Technician's Signature: <br />Date, _02LI6129-0-9 <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 />