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offir <br /> �vc <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-Lathrop (Truck Side) Date of Testing: 5/23/2011 <br /> Facility Address: 116 E Roth Road, Lathrop, CA 9533C- <br /> Facility Contact: Hardeep Gill Phone: 707-326-0369 <br /> Date Local Agency Was Notified of Testing: 5/5/2011 <br /> Name of Local Agency Inspector(fpresent during testing): Thuy Tran <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: EPIC Compliance Systems Inc. <br /> Technician Conducting Test: Al Milburn <br /> Credentials: B CSLB Contractor 0ICC Service Tech. ❑ SWRCB Tank Tester ❑ Other(Specify) <br /> License Number(s): 956953 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: 0 Hydrostatic ❑Vacuum ❑ Other <br /> Test EquipmcntUsed: 1 hr Lake Test F, ui nncnt Resolution: 1)16„ <br /> Identify Spill Bucket (By Tank 1 2 3 4 <br /> Number, Stored Product, etc.) 87 91 Diesel <br /> Bucket Installation Type: ❑Direct Bury ❑ Direct Bury ❑ Direct Bury ❑Direct 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 <br /> vacuum/water and start of test: 5 min 5 min 5 min <br /> Test Start Time(T,): 1710 1710 1710 <br /> Initial Reading(R,): 14 14.5 14.5 <br /> Test End Time(TF): 1810 1810 1810 <br /> Final Reading(Rr): 14 14.5 14.5 <br /> Test Duration(TF—T,): 1 hr 1 hr 1 hr <br /> Change in Reading(RF-R,): 0 0 0 <br /> Pass/Fail Threshold or ± 1/16" + 1/16" ± 1/16" <br /> Criteria: _ <br /> Test Result: 0 Pass ❑Fail 0 Pass ❑Fail 0 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 contained in this report is true,accurate,and in full compliance with legal requirements. <br /> Technician's Signature: ��` X612 Date: 5/23/2011 <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 />