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Appendix VIII UE020 <br /> Underground Storage Tank <br /> Spill Container Testing Report Form <br /> TYPE OF ACTION ❑ Installation ❑ Repair ❑✓ 12 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Test Date <br /> 10207012 02/02/2022 <br /> Facility Name <br /> Pacific Bell Telephone Co. dba AT&T California <br /> Facility Address City ZIP Code <br /> 124 W. Elm St. Lodi 95240 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Test Phone <br /> TAIT Environmental Services, Inc. (714) 560-8222 <br /> Mailing Address <br /> 11280 Trade Center Dr., Rancho Cordova, CA 95742 <br /> Service Technician Performing Test <br /> Reggie Velasco <br /> Contractor/Tank Tester License Number <br /> 588098 <br /> ICC Number ICC Expiration Date <br /> 9901046 03-25-2023 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> FFS EVR Phase I Systems-VR-101 1008293713 02-01-2024 <br /> 4. TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> PEI RP 1200 T1 Diesel UE0200001 spill container <br /> 5. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <br /> I hereby certify that each spill container was tested in accordance with California Code of <br /> Regulations, title 23, division 3, chapter 16, section 2637.1; that required supporting <br /> documentation is attached, and all information contained herein is accurate. I understand <br /> that test procedures shall be made available upon request by the governing authority. <br /> Service Technician Signature Date Total # of Pages <br /> ~� 02/02/2022 <br /> CERS = California Environmental Reporting System, ID = Identification, ICC = International Code <br /> Council <br /> Page 1 of 2 <br />