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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 /> printoutsfrom tests(if applicable), should be provided to thefacility owner/operatorfor submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Faci I ity Name: Fast Lane-Lathrop Auto Side Date of Testing: 6/20/2012 <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: 6/5/2012 <br /> Name of Local Agency Inspector(ifpresentdur/ngtesting): ThuyTran <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: EPIC Compliance Systems Inc. <br /> Technician Conducting Test:Al Milburn <br /> Credentials: 0 CSLB Contractor 0 ICC Service Tech. ❑ SWRCB Tank Tester ❑Other(Spec) <br /> License Number(s):956953 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: Q Hydrostatic ❑Vacuum ❑Other <br /> Test Equipment Used: 1 hr Lake Test Equipment Resolution: 1/16 <br /> Identify Spill Bucket(6y Tank 1 2 3 a <br /> Number,Stored Product, etc.) 87 91 Diesel <br /> Bucket Installation Type: <br /> El Direct Bury L3 Direct Bury ❑Direct Bury 11 Direct Bury <br /> Q Contained in Sump Q Contained in Sump Q 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(Ti): 1030 1030 1030 <br /> Initial Reading(R,): 11.25" 11.5" 12" <br /> Test End Time(TF): 1130 1130 1130 <br /> Final Reading(RF): 11.25" 11.5" 12" <br /> Test Duration(Tp—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: Q Pass ❑Fail Q Pass ❑Fail Q Pass ❑Fail ❑ Pass ❑ Fail <br /> Comments— (include information on repairs made prior to testing and recommendedfollow-upforfailed tests) <br /> All Pass <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby certify that all the information containedinthis report is true,accurate,and in full compliance with legal requirements. <br /> Technician's Signature: Date: 6/20/2012 <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 />