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`� EP®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 /> printoutsfrom tests(if applicable), should be provided to the facility owner/operatorforsubmittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Quicki Kleen I Date of Testing: 10-18-2010 <br /> Facility Address: 707 E Yosemite Ave, Manteca, CA 95336 <br /> Facility Contact: Francene Escobar I Phone: 209-814-3726 <br /> Date Local Agency Was Notified of Testing: 09-28-2010 <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: ❑CSLB Contractor 0 ICC Service Tech. 0 SWRCB Tank Tester ❑Other(Specify) <br /> License Number(s): 90-1409 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: 0 Hydrostatic ❑Vacuum ❑Other <br /> Test Equipment Used: I hr Lake Test Equipment Resolution: <br /> Identify Spill Bucket (By Tank 1 Z 3 7- <br /> Number, Stored Product, etc.) 87 South 87 North Diesel <br /> Bucket Installation Type: ❑Direct Bury Ll <br /> Direct Bury ❑Direct Try— ❑Direct Bury <br /> 0 Contained in Sum 0 Contained in SuTp 0 Contained in Sump Cl Contained in Sum <br /> Bucket Diameter: 12" 12" 12" <br /> Bucket Depth: 16.75" 17" 15" <br /> Wait time between applying 5 min 5 min 5 min <br /> vacuum/water and start of test: <br /> Test Start Time(T,): 1020 1020 1020 <br /> Initial Reading(R,): 11" 12" 13.25" <br /> Test End Time(TF): 1120 1120 1120 <br /> Final Reading(Rr): 11" 12" 13.25" <br /> Test Duration(TF—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: 0 Pass ❑Fail 0 Pass ❑Fail 0 Pass ❑Fail ❑ Pass ❑Fail <br /> Comments— (include information on repairs made prior to testing, and recommended follow-up forfailed tests) <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> 7 hereby certify that all the information contained in this report is true,accurate,and in full compliance with legal requirements. <br /> Technician's Signature: Date: 10-18-2010 <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 />