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v <br />E <br />r//// <br />�oc <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: California Stop I Date of Testing: 03/11/08 <br />Facility Address: 2224 S. Manthey Rd., Stockton, CA, 95206 <br />Facility Contact: Nancy Le I Phone: (209) 462-7621 <br />Date Local Agency Was Notified of Testing: 03/07/08 <br />Name of Local Agency Inspector (ifpresent during testing): Michell Henry <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: EPIC Compliance Systems, Inc. <br />Technician Conducting Test: Alvin L. Milburn <br />Credentials': 0 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: Caldwell level Change Indicator Equipment Resolution: .0025" <br />o� ,� 1�: <br />MM0,11,. <br />MM , <br />Identify Spill Bucket (By Tank 1 <br />Number, Stored Product, etc) 87 <br />2 3 <br />91 Diesel <br />4 <br />Bucket Installation Type: 0 Direct Bury <br />❑ Contained in Sump <br />El Direct Bury 0 Direct Bury <br />❑ Contained in Sump ❑ Contained in Sump <br />❑ Direct Bury <br />❑ Contained in Sump <br />Bucket Diameter: 12 <br />12 12 <br />Bucket Depth: <br />12 <br />12 12 <br />Wait time between applying <br />vacuum/water and start of test: <br />5 min <br />5 min 5 m i n <br />Test Start Time (Tj): <br />12:05 <br />11:20 10:45 <br />Initial Reading (RI): <br />0 <br />0 0 <br />Test End Time (TF): <br />12:35 <br />11:50 11:15 <br />Final Reading (RF): <br />0 <br />Off scale 0 <br />Test Duration (TF— Tt): <br />1/Z hour <br />1/Z hour 1/Z hour <br />Change in Reading (RF - RI): <br />0 <br />- 0 <br />Pass/Fail Threshold or <br />Criteria: <br />0 <br />0 0 <br />Test Result: <br />0 Pass U,Fail <br />❑ Pass 0 Fail ® PassQ Fail <br />❑Pass D Fail <br />Comments — (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br />91 spill bucket has a steady loss of water. The drain valve is not leaking. <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: <br />Date: 03/11/08 <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 />