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SWRCB,January 2006 <br /> Spill Bucket Testing Deport Form <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(if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Fast Lane Central Valley (Truck Side) Date of Testing: 6/17/2016 <br /> Facility Address: 116 East Roth Road, Lathrop, CA 95330 <br /> Facility Contact: Hardeep Gill Phone: 707-326-0369 <br /> Date Local Agency Was Notified of Testing 6/3/2816 <br /> Name of Local Agency Inspector(if present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: EPIC Environmental Compliance Systems, Inc. <br /> Technician Conducting Test:Alvin Milburn <br /> Credentials': Z CSLB Contractor 0 ICC Service Tech. ❑ SWRCB Tank Tester ❑Other(Specify) <br /> License Number(s):956593 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: Q Hydrostatic ❑ Vacuum ❑Other <br /> Test Equipment Used: 1 hr Lake test Equipment Resolution: 1/16" <br /> Identify Spill Bucket(By Tank 1 2 3 a <br /> Number, Stored Product, etc.) Diesel South Diesel North <br /> Bucket Installation Type: LJDirect Bury LJDirect Bury LJDirect Bury LJDirect Bury <br /> Q Contained in Sump Q Contained in Sump ❑Contained in Sump ❑Contained in Sump <br /> Bucket Diameter: 12" 12" <br /> Bucket Depth: 15" 15" <br /> Wait time between applying <br /> vacuum/water and start of test: 5 min 5 min r � <br /> Test Start Time(Ti): 1815 1015 a <br /> Initial Reading(Rr): 13 1/8" 13 3/e„ <br /> Test End Time(TF): 1115 1115 NOV 0 2 2016 <br /> Final Reading(RF): 13 1/8" 13 3/8" <br /> Test Duration(TF—Tj): 1 hr 1 hr FNVIRCiNMENTAI HEA1H <br /> Change in Reading(RI;- Ri): 0 0 DEPARTMENT <br /> Pass/Fail Threshold or 8 0 <br /> Criteria: <br /> Test Result: 0 Pass ❑ Fail W Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail <br /> Comments—(include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> All Pass <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby certify that all the information <br /> Gc'on�tainedd%in this report is true,accurate,and in full compliance with legal requirements. <br /> Technician's Signature: rz Date: 6/17/2016 <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 />