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6FF/C <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 facilityowner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Quickie KleenDate of Testing: 10/21/2009 <br /> Facility Address: 707 East Yosemite Ave Manteca, CA 95336 <br /> Facility Contact: Francene Escobar Phone: 209-814-6274 <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(if present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: EPIC Compliance Systems, Inc. <br /> Technician Conducting Test: Keith Huston <br /> Credentials: ®CSLB Contractor ❑ICC Service Tech. ❑ SWRCB Tank Tester ❑ Other(Spec) <br /> License Number(s): 880430 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ❑ Hydrostatic ❑Vacuum ❑Other <br /> Test Equipment Used: Equipment Resolution: <br /> Identify Spill Bucket (By Tank 1 Regular 1 2 Regular 2 3 Diesel 4 <br /> Number, Stored Product, etc.) _ <br /> Bucket Installation Type: ❑Direct Bury ❑Direct Bury ❑Direct Bury L3 Direct Bury <br /> D Contained in Sump CO Contained in Sump x❑Contained in Sump ❑Contained in Sum <br /> Bucket Diameter: 12" 12" 12" <br /> Bucket Depth: 16 3/4" 17 '/z" 16" <br /> Wait time between applying 5 minutes 5 minutes 5 minutes <br /> vacuum/water and start of test: <br /> Test Start Time(Tt): 10:15 AM 10:15 AM 02:30 PM <br /> Initial Reading(R,): 15 7/8" 16 3/4" 15 Yz" <br /> Test End Time(TF): 11:15 PM 11:15 PM 03:30 PM <br /> Final Reading(RF): 15 7/8" 16 3/4" 15 Yz" <br /> Test Duration(TF—T,): 1 hour 1 hour 1 hour <br /> Change in Reading(RF-R,): 0 0 0 <br /> Pass/Fail Threshold or <br /> Criteria: <br /> Test Result: El Pass ❑Fail © 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 /> 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 /> >1 <br /> Technician's Signature: Date: 10/21/2009 <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 />