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Appendix VII UE020 <br /> Underground Storage Tank <br /> Secondary Containment Testing Report Form <br /> TYPE OF ACTION ❑ Installation p Repair ❑ 6 Month ❑ 36 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Test Date <br /> 10207012 02/12/2024 <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 /> Max Hines <br /> Contractor/Tank Tester License Number <br /> 588098 <br /> ICC Number ICC Expiration Date <br /> 8750053 9/27/2025 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> Veeder Root 3/9/2024 <br /> 4. TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> PER PEI 1200 T1:ANNULAR,VENT LINE & HYYDROSTATIC SUMP TEST <br /> 5. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <br /> I hereby certify that the secondary containment was tested in accordance with California <br /> Code of Regulations, title 23, division 3, chapter 16, section 2637; 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 /> * —,ZA— 02/12/2024 <br /> CERS = California Environmental Reporting System, ICC = International Code Council, <br /> ID = Identification, NA = Not Applicable, UDC = Under-Dispenser Containment, <br /> Page 1 of 5 <br />