Laserfiche WebLink
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/operatorfor submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> FacilityName: Fast Lane-Lathrop Truck 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(ifpresent during testing): Thuy Tran <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: EPIC Compliance Systems Inc. <br /> Technician Conducting Test:Al Milburn <br /> Credentials: RI CSLB Contractor D 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(By Tank 1 2 3 4 <br /> Number, Stored Product, etc.) Diesel South Diesel North <br /> Bucket Installation Type: <br /> LI Direct Bury ❑ Direct Bury Ll Direct Bury ❑Direct Bury <br /> Q Contained in Sump Q Contained in Sump ❑Contained in Sump ❑Contained in Sump <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,): 1330 1330 <br /> Initial Reading(R,): 115/g" 11.50" <br /> Test End Time(TF): 1430 1430 <br /> Final Reading(RF): 115/8- 11.50" <br /> Test Duration(TF—T,): 1 hr 1 hr <br /> Change in Reading(RF-R,): 0 0 <br /> Pass/Fail Threshold or 0 0 <br /> Criteria: <br /> Test Result: Q Pass ❑Fail Q Pass LlFail=j ❑ Pass ❑Fail ❑ Pass ❑Fail <br /> Comments—(include information on repairs made prior to testing and reconunended 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 containedin this report is true,accurate,and in fhdl compliance with legal requirements. <br /> Technician's Signature: /C/ 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 />