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0 <br />Spill Bucket Testing Report Form <br />Thisform 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 ownerloperator for submittal to the local regulatory agency. <br />IT Me <br />Dat, of Testing: 11/30/2009y Name: Nick's Shell <br />-Facility Address: 16500 S Harlan Rd Lathrop, CA 95330 <br />Facility Contact: Chris Phone: 619-518-8378 <br />Date Local Agency Was Notified of Testing: 11/24/20009 <br />Name of Local Agency Inspector (if present 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 . 9 CSLB Contractor LJ ICC Service Tech- U SWRCB Tank Tester U Other (Specify) <br />License Number(s): 880430 <br />RNHTM�. ,i� <br />Test Method Used: <br />[91 Hydrostatic <br />Ll Vacuum <br />L) Other <br />Test Equipment Used: I hour LAKE Test <br />M <br />Identify Spill Bucket By Tank 1 Premium 91 <br />Number, Stored Product, etc.) <br />R <br />2 <br />Equipment Resolution: <br />3 <br />-------- <br />4 <br />_ <br />Bucket Installation Type: <br />ffl Direct Bury <br />L3 Contained in Swnp <br />Ll Direct Bury <br />LJ Contained in Sump <br />0 Direct Bury <br />Q Contained in Sump <br />Ll Direct Bury <br />U Contained in Sump <br />Bucket Diameter: <br />12" <br />Bucket Depth: <br />13 1/4 <br />Wait time between applying <br />vacuum/water and start of test: <br />5 minutes <br />Test Start Time (TI): <br />12:10 PM <br />Initial Reading (RD: <br />127/8 - <br />Test End Time (TF): <br />1:10 PM <br />Final Reading (RF): <br />12 7/8" <br />Test Duration (TF - TI): <br />1 hou r <br />Change in Reading (RF - Rj): <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />0 <br />Test Result: <br />nx Pass L]Fail <br />L] Pass Ll Fail <br />Ll Pass Ll Fail <br />Ll Pass Ll Fail <br />Coencs— (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 requiremen& <br />Technician's Signature: 6�w 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 />