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low <br /> ~ Pagel of 8 0/// sYs'FM9 L <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 owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Verizon Lodi Date of Testing: 05/14/2010 <br /> Facility Address: 2500 West Turner Road Lodi, CA, 95242 <br /> Facility Contact: Todd Harris Phone: 972-729-5671 <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(if present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: EPIC Compliance Systems <br /> Technician Conducting Test: Keith Huston <br /> Credentials: 2 CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester <br /> License Type: A License Number:880430 <br /> Manufacturer Training <br /> Manufacturer Components Date Training Expires <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> Tank Annular 0 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Sec. Piping #1 0 ❑ ❑ ❑ _ ❑ ❑ ❑ ❑ <br /> Sec. Piping #2 Rl ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Sump North © ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Sump South 0 ❑ ❑ ❑ ❑ ❑ ❑ U <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ J ❑ ❑ ❑ ❑ <br /> ❑ ❑ C] J ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ I ❑ ❑ ❑ ❑ <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 Me facts stated in Mis document are accurate and in full compliance with legal requirements <br /> Technician's&gnature:: Date: 05/14/2010 <br />