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22 <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/operator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: Kwik Serve I Date of Testing: 10/30/08 <br />Facility Address: 950 W. 11th Street, Tracy, CA, 95376 <br />Facility Contact: Patel I Phone: 209-832-1810 <br />Date Local Agency Was Notified of Testing: 10/10/08 <br />Name of Local Agency Inspector (ifpresent during testing): Garret Backus <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: EPIC Compliance Systems, Inc. <br />Technician Conducting Test: Alvin L. Milburn <br />Credentials' Rl CSLB Contractor ICC Service Tech. SWRCB Tank Tester Other (Sped) <br />License Number(s): 880430 <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: 21 Hydrostatic U Vacuum U Other <br />Test Equipment Used: 1 Hour <br />Lake Test <br />Equipment Resolution: <br />�: ..,. . ; , ,,,,, .,. ,zx <br />� < � , <br />s ��� ,.. �-, ,,,.. <br />.._. „ n�s� ,. � r <br />� Wiz•..•. <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc. <br />1 <br />Diesel <br />2 <br />Premium <br />3 <br />Regular <br />4 <br />Bucket Installation Type: <br />O Direct Bury <br />❑ Contained in Sump <br />❑x Direct Bury <br />a Contained in Sump <br />x❑ Direct Bury <br />❑ Contained in Sump <br />❑ Direct Bury <br />❑ Contained in Sump <br />Bucket Diameter: <br />12" <br />12" <br />12" <br />Bucket Depth: <br />16" <br />11.5" <br />13.5" <br />Wait time between applying <br />vacuum/water and start of test: <br />5 min <br />5 min <br />5 m i n <br />Test Start Time (Tj): <br />10:00 <br />10:30 <br />11:30 <br />Initial Reading (Rt): <br />143/4- <br />10" <br />12" <br />Test End Time (TF): <br />11:00 <br />11:30 <br />12:30 <br />Final Reading (RF): <br />143/4- <br />10" <br />12" <br />Test Duration (TF - TI): <br />1 hr <br />1 hr <br />1 hr <br />Change in Reading (RF - Ri): <br />0 <br />0 <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />0 <br />0 <br />0 <br />Test Result: <br />CI Pass LI ]fail <br />0,Pass U Fail <br />(@'Pass'' R Fail <br />D Pass,CI.Faii <br />Comments — (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br />All Pass. <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />hereby certify that all the information contained in this report is true, accurate, and in full compliance with legal requirements. <br />Technician's Signature: <br />Date: 10/30/08 <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 />