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0i�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 (f 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 (Auto) I DateofTesting: 12/8/2010 <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: 12/1/2010 <br /> Name of Local Agency Inspector(ifprerent during testing): Th uy Tran <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: EPIC Compliance Systems, LLC <br /> Technician Conducting Test: Al Milburn <br /> Credentials': ❑CSLB Contractor 0 ICC Service Tech. El SWRCB Tank Tester ❑Other(Specify) <br /> License Number(s): 90-1409 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: 0 Hydrostatic ❑ Vacuum ❑ Other <br /> Test Equipment Used: 1hour Lake Test Equipment Resolution: --- <br /> Identify Spill Bucket (By Tank 1 2 3 4 <br /> Number, Stored Product, etc.) 87 91 Diesel <br /> Burke[Installation Type: <br /> E3 Direct Bury ❑Direct Bury Cl Direct Bury L3 Direct Bury <br /> ❑Contained in Sump ❑Contained in Sump ❑x Contained in Sump ❑Contained in Sum <br /> Bucket Diameter: 12" 12" 12" <br /> Bucket Depth: 14.75" 15" 15" <br /> Wait time between applying 5 rein 5 min 5 min <br /> vacuum/water and start of test: <br /> Test Start Time(T,): 1150 1150 1150 <br /> Initial Reading(R,): 12" 12" 12" <br /> Test End Time(TF): 1250 1250 1250 <br /> Final Reading(RF): 12" 12" 12" <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 0 0 0 <br /> Criteria: <br /> Test Result: ❑x Pass ❑Fail ❑x Pass ❑ Fail ❑O Pass ❑Fail ❑ Pass ❑Fail <br /> Comments—(include information on repairs made prior to testing, and recommended follow-up forfailed 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: Date: 12/08/2010 <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 />