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0 0 0////r - <br /> Spill Bucket Testing Report Form <br /> P g P <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(if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Nick's Shell I Date of Testing: 11/30/2009 <br /> Facility Address: 16500 Harlan Rd Lathrop, CA 95330 <br /> Facility Contact: Chris I Phone: 619-518-8378 <br /> Date Local Agency Was Notified of Testing: 11/24/20009 <br /> Name of Local Agency Inspector(tfpresent during testing): Michelle Henry <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: EPIC Compliance Systems, Inc. <br /> Technician Conducting Test: Alvin L Milburn <br /> Credentials': El 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: 1 hour LAKE Test Equipment Resolution: -------- <br /> 77777 <br /> Identify Spill Bucket(By Tank 1 Premium 91 2 3 4 <br /> Number, Stored Product, etc.) <br /> Bucket Installation Type: ❑x Direct Bury ❑Direct Bury ❑Direct Bury ❑Direct Bury <br /> ❑Contained in Sump ❑Contained in Sum ❑Contained in Sump ❑Contained in Sump <br /> Bucket Diameter: 12" <br /> Bucket Depth: 13 1/4" <br /> Wait time between applying <br /> vacuum/water and start of test: 5 minutes <br /> Test Start Time(Ti): 12:10 PM <br /> Initial Reading(RI): 12 7/8" <br /> Test End Time(TF): 1:10 PM <br /> Final Reading(RF): 12 7/8" <br /> Test Duration(TF—Tj): 1 hour <br /> Change in Reading(RF-RI): 0 <br /> Pass/Fail Threshold or 0 <br /> Criteria: <br /> Test Result: ® Pass ❑Fail ❑ Pass ❑Fail ❑ Pass ❑Fail ❑ Pass D 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 /> Technician's Signature: Date: 11/30/2009 <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 />