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w^ • r/a <br /> svaP1rEmswce <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 /> 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: Tracy Truck Stop I Date of Testing: 04/02/2010 <br /> Facility Address: 3940 N Tracy Blvd Tracy, CA 95304 <br /> Facility Contact: Debbie Jutla Phone: 209-832-5006 <br /> Date Local Agency Was Notified of Testing: - <br /> Name of Local Agency Inspector(fpresent during testing): Michele Henry <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: EPIC Compliance Systems, Inc. <br /> Technician Conducting Test: Keith Huston <br /> Credentials': ®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: N Hydrostatic ❑Vacuum ❑ Other <br /> Test Equipment Used: Lake Test Equipment Resolution: - <br /> Identify Spill Bucket(By Tank 1 2 3 4 <br /> Stored Product, <br /> Number, St <br /> etc.) 87 91 West HFIo East HFIo <br /> Bucket Installation Type: ®Direct Bury l]Direct Bury 0 Direct Bury n Direct Bury <br /> ❑Contained in Sump ❑Contained in Sump ❑Contained in Sump ❑Contained in Sum <br /> Bucket Diameter: 12" 12" 12" 12" <br /> Bucket Depth: 14" 13" 12" 13" <br /> Wait time between applying <br /> vacuum/water and start of test: 5 m i n 5 m i n 5 m i n 5 m i n <br /> Test Start Time(TI): 09:35 AM 09:35 AM 12:50 PM 03:15 PM <br /> Initial Reading(RI): 13 3/4" 12 7/8" 11 7/16" 129/16- <br /> Test <br /> 29/16"Test End Time(TF): - 10:35 AM 01:50 PM 04:00 PM <br /> Final Reading(RF): - 12 7/8" 11 7/16" 12 9/16" <br /> Test Duration(TF—T j): - 1 hr l hr 45 m i n <br /> Change in Reading(RF-RI): - 0 0 0 <br /> Pass/Fail Threshold or _ 0 0 0 <br /> Criteria: <br /> Test Result. ❑ Pass ZFail ® Pass '' ❑Fail ® Pass ❑Fail ® Pass ❑Fail <br /> Comments— (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> 87 spill bucket needs to be replaced. <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: j` Date: 04/02/2010 <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 />