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w <br /> ' s <br /> 0////C <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(if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Gas Depot I Date of Testing: 11/25/08 <br /> Facility Address: 1330 E. Yosemite Ave, Manteca, CA 95336 <br /> Facility Contact: Ricky I Phone: (209) 825-0332 <br /> Date Local Agency Was Notified of Testing: 11/04/08 <br /> Name of Local Agency Inspector(if present during testing): <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: El Hydrostatic ❑Vacuum ❑Other <br /> Test Equipment Used: 1 Hr. Lake Test Equipment Resolution: <br /> n.7 r <br /> Identify Spill Bucket(By Tank1 2 3 4 <br /> Number, Stored Product, etc.) 87 91 Diesel <br /> Bucket Installation Type: ®Direct Bury ❑ Direct Bury ❑Direct Bury ❑Direct Bury <br /> ®Contained in Sum ®Contained in Sump ®Contained in Sump ❑Contained in Sump <br /> Bucket Diameter: 12" 12" 12" <br /> Bucket Depth: 12" 14" 14" <br /> Wait time between applying <br /> vacuum/water and start of test: 5 m i n 5 m i n 5 m i n <br /> Test Start Time(Tj): 12:00 12:00 12:00 <br /> Initial Reading(Ri): 10.5" 10.5" 13" <br /> Test End Time(TF): 13:00 13:00 13:00 <br /> Final Reading(RF): 10.5" 10.5" 13" <br /> Test Duration(TF—Tj): 1 hr 1 hr 1 hr <br /> Change in Reading(RF-Rj): 0 0 0 <br /> Pass/Fail Threshold or 0 0 0 <br /> Criteria: <br /> Test Result: O Pass ®Fail Fxl Pass ❑Fail [XI Pass U Faith ❑Pass ❑Fail <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 /> 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: 11/25/08 <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 />