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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 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 (Auto Side) Date of Testing: 6/19/2017 <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: 4/18/2017 <br /> Name of Local Agency Inspector(if present during testing): Vicki McCartney <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: EPIC Environmental Compliance Systems Inc. <br /> Technician Conducting Test: 'Brian Dunahay <br /> Credentials': Z CSLB Contractor 10 ICC Service Tech. ❑ SWRCB Tank Tester ❑ Other(Spec) <br /> License Number(s): 956593 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: A Hydrostatic ❑Vacuum =!Other <br /> Test Equipment Used: 1 hr lake test Equipment Resolution: 1/16" <br /> Identify Spill Bucket(By Tank 1 87 2 91 3 Diesel 4 <br /> Number, Stored Product, etc.) <br /> Bucket Installation Type: ❑Direct Bury ❑Direct Bury ❑Direct Bury ❑Direct Bury <br /> ❑Contained in Sump R1 Contained in Sump ®Contained in Sump ❑Contained in Sump <br /> Bucket Diameter: 12" 12" 12" <br /> Bucket Depth: 14.75" 15" 15" <br /> Wait time between applying <br /> vacuum/water and start of test: 5 min 5 min 5 m i n <br /> Test Start Time(Ti): 1400 1100 1100 <br /> Initial Reading(R,): 13.5" 14" 13.5" <br /> Test End Time(TF): 1500 1200 1200 <br /> Final Reading(RF): 13.5" 14" 13.5" <br /> Test Duration(TF—Tr): 1 hr 1 hr 1 hr <br /> Change in Reading(RF-Rt): 0 0 0 <br /> Pass/Fail Threshold or 0 0 0 <br /> Criteria: <br /> Test Result: ® Pass ❑Fail 0 Pass ❑Fail ❑ Pass L1 Fail ❑ Pass ❑Fail <br /> Comments—(include information on repairs made prior to testing, and r•ecornmended follow-arp,for failed tests) <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING 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: _ Date: 6/19/2017 <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 />