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b <br />AC 0 R 6 <br />t <br />Ll <br />0 �, -x"i(,C_ft <br />Page 1 <br />Secondary Containment & Overfill Containment <br />Testing Report Form <br />1. FACILITY INFORMATION <br />Facility Name: MCI Verizon T Date of 2/12/07 <br />Facility Address: 13850 Devries Rd., Lodi CA <br />Facility Contact: Todd Harris Phone: 972-729-5671 <br />Date Local Agency Was Notified of Testing: 2/8/07 <br />Name of Local Agency Inspector (:f present during testing): Munia a Naidu <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: Balch Petroleum Contractors & Builders Inc. <br />Technician Conducting Test: Vic Ramirez <br />Credentials: X CSLB Licensed Contractor <br />❑ SWRCB Licensed Tank Tester <br />License Type: A / B / C-10 / HAZ <br />Manufacturer <br />License Number: 396575 <br />Manufacturer Training <br />Com onent s) Date Trainin Expires <br />Ronan Hydrostatic Precision Test Equipment NA <br />3. SIJMMARY OF TEST RF,SIJLTS <br />Notes: <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: 2/12/07 <br />I : \appsUOB S\2006\ 1493\SB989. doc <br />Piping <br />,- <br />©000 <br />000' <br />Piping <br />©oQOi <br />QooO <br />Transition <br />©oo� <br />oaoio <br />. , <br />- <br />©000 <br />aaoo <br />. <br />.. ,. <br />©000 <br />0000 <br />Vent Secondary©000 <br />0000 <br />' - <br />o000 <br />0000 <br />0000 <br />0000 <br />0000 <br />0000 <br />0000 <br />0000 <br />0000 <br />mom= <br />0000 <br />0000 <br />0000 <br />0000 <br />Notes: <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: 2/12/07 <br />I : \appsUOB S\2006\ 1493\SB989. doc <br />