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Spill Bucket Testing Report Form OR <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/operatorfor submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Fast Lane-Lathrop (Truck Side) Date of Testing: October 27, 2010 <br /> FacilityAddress: 116 East Roth Road Lathrop, CA 95330 <br /> Facility Contact: Hardeep Gill I Phone: 707-326-0369 <br /> Date Local Agency Was Notified of Testing: October 13, 2010 <br /> Name of Local Agency Inspector(ifpresent during testing): Michelle Henry <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: EPIC Compliance Systems, LLC <br /> Technician Conducting Test:AI Milburn <br /> Credentials: ❑CSLB Contractor 8 ICC Service Tech. a SWRCB Tank Tester ❑ Other(Specify) <br /> License Number(s):90-1409 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ❑X Hydrostatic ❑Vacuum ❑ Other <br /> Test Equipment Used: 1 Hr Lake Test Equipment Resolution: --- <br /> Identify Spill Bucket (By Tank 1 Diesel 2 Diesel 3 4 <br /> Number, Stored Product, etc.) North South <br /> Bucket Installation Type: <br /> L3 Direct Bury ❑Direct Bury LJ Direct Bury Ll Direct Bury <br /> ❑D Contained in Sump ❑O Contained in Sump ❑Contained in Sump ❑Contained in Sum <br /> Bucket Diameter: 12" 12" <br /> Bucket Depth: 15" 15" <br /> Wait time between applying 5 min 5 min <br /> vacuum/water and start of test: <br /> Test Start Time(T,): 15:15 15:15 <br /> Initial Reading(Rj): 12.5" 12.25" <br /> Test End Time(TF): 16:15 16:15 <br /> Final Reading(RF): 12.5" 12.25" <br /> Test Duration(Tp—Tt): 1 hr 1 hr <br /> Change in Reading(RF-Rj): 0 0 <br /> Pass/Fail Threshold or 0 0 <br /> Criteria: <br /> Test Result: O Pass ❑Fail Pass ❑Fail ❑ Pass ❑Fail ❑ Pass ❑Fail <br /> Comments— (include information on repairs made prior to testing, and recommended follow-up 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 /> y f., <br /> Technician's Signature: Date: October 27, 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 /> � 1 , <br />