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SWRCB,January 2006 <br /> Spill Bucket Testing Report Form <br /> This form is intended for use by contractors performing annual testing of()'ST spill containment structures. The completed farm 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: East Lane Central Valley � I Date of Testing: 6/16/2016 <br /> Facility Address: 116 East Roth Rd, Lathrop, CA 95330 <br /> Facility Contact: Hardeep Gill Phone: 707-326-0369 <br /> Date Local Agency Was Notified of Testing: 6/3/2016 <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': Fl CSLB Contractor 19 ICC Service Tech. ❑ SWRCB Tank Tester ❑Other(Spec) <br /> license Number(s): 956593 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> "Fest Method Used: 0 Hydrostatic ❑ Vacuum ❑ Other <br /> Test Equipment Used: 1 hr lake test Equipment Resolution: 1/16" <br /> Identify Spill Bucket(By Tank 1 2 3 d <br /> Number, Stored Product, etc.) 87 91 Diesel <br /> Bucket Installation Type: LJDirect Bury LlDirect Bury LlDirect Bury LlDirect Bury <br /> 0 Contained in Sump 0 Contained in Sump 0 Contained in Sump ❑ Contained in Sump <br /> Bucket Diameter. 12" 12" 12" <br /> Bucket Depth: 14.75" 15" 15" <br /> Wait time between applying 5 min 5 min 5 min <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 10:00 10:00 10:00 <br /> Initial Reading(RI): 13 1/8" 13 1/8" 13 1/4" <br /> Test End Time(TF): 11:00 11:00 11:00 <br /> Final Reading(RF): 13 1/8" 13 1/8" 13 1/4" <br /> Test Duration(TF—Tj): 1 hr 1 hr 1 hr <br /> Change in Reading(RF-Ri): 0 0 0 <br /> Pass/Fail Threshold or 0 0 0 <br /> Criteria: <br /> Test Result: Z Pass ❑ Fail Rl Pass ❑ Fail © Pass 0 Fail ❑ Pass ❑ Fail <br /> Comments—(include information on repairs made prior to testing, and recomm de ! -ar i ests) <br /> All Pass <br /> NOV 0 2 2016 <br /> ENVIRONMENTAL HTEALTH <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR C� DUTIIiIG THIS TESTING <br /> I hereby certify that all the information contained in this report is true, accurate,and in full compliance with legal requirements. <br /> Technician's Signature: (�Z—- 0�� Date: 6/16/2016 <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 />