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0 <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: Tracy Blvd Shell I Date ofTesting: 1/5/2011 <br /> Facility Address: 3725 Tracy Blvd Tracy, CA 95304 <br /> Facility Contact: Mojgan Anvari I Phone: 510-224-6922 <br /> Date Local Agency Was Notified of Testing: 12/28/2010 <br /> Name of Local Agency Inspector(ifpresent during testing): Thuy Tran <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: EPIC Compliance Systems, Inc. <br /> Technician Conducting Test:Al M i I bu rn <br /> Credentials: ❑CSLB Contractor 0 ICC Service Tech. 21 SWRCB Tank Tester ®Other(Specify) <br /> License Number(s): 90-1409 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: 0 Hydrostatic ❑Vacuum U Other <br /> Test Equipment Used: 1 hr Lake Test Equipment Resolution: --- <br /> Identify Spill Bucket(By Tank 1 87 2 89 3 91 4 Diesel <br /> Number, Stored Product, etc.) <br /> Bucket Installation Type: 0 Direct Bury U Direct Bury C)Direct Bury U Direct Bury <br /> ®Contained in Sump Q Contained in Sump Rl Contained in Sump Q Contained in Sum <br /> Bucket Diameter: 12" 12" 12" 12" <br /> Bucket Depth: 13.5" 13.5" 13.5" 13.5" <br /> Wait time between applying <br /> vacuum/water and start of test: 5min 5min 5min 5 m i n <br /> Test Start Time(Tj): 1330 1330 1330 1330 <br /> Initial Reading(Rj): 13.5" 13.5" 13.5" 13.5" <br /> Test End Time(TF): 1430 1430 1430 1430 <br /> Final Reading(RF): 13.5" 13.5" 13.5" 13.5" <br /> Test Duration(TF—Tj): 1 hr 1 hr 1 hr 1 hr <br /> Change in Reading(RF-Ri): 0 0 0 0 <br /> Pass/Fail Threshold or 0 0 0 0 <br /> Criteria: <br /> Test Result: Q Pass,.' CiFail Q Pass OFaii Q Pass; ❑Fail Q Pass UFaiI <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: 0"`z;PW ,—, Date: 1/5/2011 <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 />