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CUMVLIANGE Spill Bucket Testing Report Form This form is intended for use by contractors performing annual testing of UST spill containment structures. The completed form and printouts from tests(f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. 1. FACILITY INFORMATION Facility Name: Van De Pol I Date of Testing: 08/04/2009 Facility Address: 357 Beckman Road Lodi, CA 95240 Facility Contact: Ted Phone: (209) 649-8308 Date Local Agency Was Notified of Testing: 07/29/2009 Name of Local Agency Inspector(ifpresent during testing): Aris Cacapit 2. TESTING CONTRACTOR INFORMATION Company Name: EPIC Compliance Systems, LLC Technician Conducting Test: Keith Huston Credentials': 10 CSLB Contractor ❑ ICC Service Tech. ❑ SWRCB Tank Tester ❑ Other(Specify) License Number(s): 880430 3. SPILL BUCKET TESTING INFORMATION Test Method Used: ®Hydrostatic ❑Vacuum ❑ Other Test Equipment Used: 1 hour LAKE Test Equipment Resolution: Identify Spill Bucket(By Tank Diesel Tank 5 2 3 4 Number, Stored Product, etc.) 11 Bucket Installation Type: ❑Direct Bury ❑Direct Bury ❑Direct Bury ❑Direct Bury El Contained in Sump ❑Contained in Sump ❑Contained in Sump ❑Contained in Sum Bucket Diameter: 12" Bucket Depth: 14" Wait time between applying vacuum/water and start of test: 5 minutes Test Start Time(Ti): 03:15 PM Initial Reading(Ri): 13 1/2" Test End Time(TF): 04:15 PM Final Reading(RF): 13 1/z" Test Duration(TF—Ti): 1 hour Change in Reading(RF-RI): 0 Pass/Fail Threshold or 0 Criteria: Test Result: rx1 Pass ❑Fail ❑ 'Pass ❑Fail O bass ❑ Fail ❑ Pass ❑Fail Comments—(include information on repairs made prior to testing, and recommended follow-up for failed tests) CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING I hereby certify that all the information contained in this report is true,accurate,and in full compliance with legal requirements. Technician's Signature: 7 Date: 08/04/2009 ' State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements may be more stringent.