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%we �"o <br /> EPEC <br /> Spill Bucket Testing Report Form <br /> This form is intendedfor 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 facilityowner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Quicki Kleen Date of Testing: 11/21/08 <br /> Facility Address: 707 E. Yosemite Ave, Manteca, CA 95336 <br /> Facility Contact: Francene Phone: (208) 814-6274 <br /> Date Local Agency Was Notified of Testing: 11/04/08 <br /> Name of Local Agency Inspector(ifpresent during testing): Muniappa Maidu <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: EPIC Compliance Systems, Inc. <br /> Technician Conducting Test: Alvin L. Milburn <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: 0 Hydrostatic ❑Vacuum ❑Other <br /> Test Equipment Used: I Hour Lake Test Equipment Resolution: <br /> Identify Spill Bucket(eyTank 1 2 3 4 <br /> Number, Stored Product,etc. 87 South 87 Middle Diesel <br /> Bucket Installation Type: U Direct Bury Ll Direct Bury Ll Direct Bury Ll Direct Bury <br /> ❑Contained in Sump ©Contained in Sum ❑Contained in Somp ❑Contained in Sump <br /> Bucket Diameter: 12" 12" 12" <br /> Bucket Depth: 16" 16" 14.5" <br /> Wait time between applying 5 min 5 min 5 min <br /> vacuum/water and start of test: <br /> Test Start Time(T,): 11:30 11:30 11:30 <br /> Initial Reading(R,): 13.5" 14" 13.5" <br /> Test End Time(Tr): 12:30 12:30 12:30 <br /> Final Reading(Rr): 13.5" 14" 13.5" <br /> Test Duration(Tr—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: M Pass ❑ Fail 21 Pass El Fail ❑D Pass ❑ Fail ❑Pass ❑ Fai► <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 /> /hereby certify that all the informationcontainedin this report is true,accurate,and in full compliance with legal requirements. <br /> Technician's Signature: Date: 11/21/08 <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 />