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v <br />III�' : '�1 <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 (f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: Verizon Date of Testing: 09/16/2008 <br />Facility Address: 13859 N Devries Road, Lodi CA 95242 <br />Facility Contact: Christine Lagat-Nakamori Phone: (925) 567 6098 <br />Date Local Agency Was Notified of Testing: 08/13/2008 <br />Name of Local Agency Inspector (fpresent during testing): Aris Cacapit <br />Company Name: EPIC Compliance Systems, Inc. <br />Technician Conducting Test: Nikola Zagorov <br />Credentials': Q CSLB Contractor ICC Service Tech. SWRCB Tank Tester Other (Spec) <br />License Number(s): 880430 <br />Test Method Used: 0 Hydrostatic Vacuum Other <br />Test Equipment Used: Tape Measure <br />Equipment Resolution:1/16 Inches <br />M <br />d... , m.Y !: H. ,. ' F-_ <br />t, c� ril., ",.. .< < 4�b� �... .�v�'�.a, <br />:T::..�.. ...J` .r 4.�., eF�,::.r.�E /, --o �. <br />.z`,ri✓.. <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc) <br />1 Tank #1 <br />Diesel <br />2 <br />3 <br />4 <br />Bucket Installation Type: <br />_ <br />- Direct Bury <br />2 Contained in Sump <br />Direct Bury <br />Contained in Sump <br />Direct Bury <br />Contained in Sump <br />: Direct Bury <br />Contained in Sump <br />Bucket Diameter: <br />12" <br />Bucket Depth: <br />13" <br />Wait time between applying <br />vacuum/water and start of test: <br />10 m i n <br />Test Start Time (TI): <br />12:30 PM <br />Initial Reading (R,): <br />12i " <br />Test End Time (TF): <br />1:30 PM <br />Final Reading (RF): <br />12 1/4" <br />Test Duration (TF—TI): <br />1 Hour <br />Change in Reading (RF - RI): <br />oil <br />Pass/Fail Threshold or <br />Criteria: <br />+/- 1/16 - <br />Test Result: <br />CEJ Pass 0 Fail <br />0 i Pass 0 Fail <br />0 Pass 0 Fail <br />0 Pass 0 Fail <br />Comments — (include information on repairs made prior to testing, and recommended follow-up for failed tests) <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 />Technician's Signature: N zCa ` 1 r ®✓ Date: 09/16/2008 <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 />