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Spill Bucket Testing Report Form <br />a <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: Verizon <br />Date of Testing: 9/14/2011 <br />Facility Address: 13850 Devries Road, Lodi, CA 95242 <br />Facility Contact: Jonathan Pakele Phone: 916-439-6042 <br />Date Local Agency Was Notified of Testing: 8/24/2011 <br />Name of Local Agency Inspector (ifpresent during testing): Aris Cacapit <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: EPIC Compliance Systems Inc. <br />Technician Conducting Test: Alvin L. Milburn <br />Credentials': Q CSLB Contractor Q ICC Service Tech. ❑ SWRCB Tank Tester ❑ Other (Specify) <br />License Number(s): 956593 <br />3. SPELL BUCKET TESTING INFORMATION <br />Test Method Used: Q Hydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: 1 hr Lake Test Equipment Resolution: <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc. <br />1 <br />Diesel <br />2 3 <br />arm - <br />4 <br />Bucket Installation Type: <br />®Direct Bury <br />Q Contained in Sum <br />❑Direct Bury LJ Direct Bury <br />❑ Contained in Sum ❑ Contained in Sum <br />❑Direct Bury <br />❑ Contained in Sum <br />Bucket Diameter: <br />12" <br />Bucket Depth: <br />13" <br />Wait time between applying <br />vacuum/water and start of test: <br />5 m I n <br />Test Start Time (T1): <br />0910 <br />Initial Reading (RI): <br />2" <br />Test End Time (TF): <br />1010 <br />Final Reading (RF): <br />2" <br />Test Duration (TF — Tj): <br />1 hr <br />Change in Reading (RF - Ri): <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />0 <br />Test Result: <br />Q- Pass ❑Fail <br />❑ Pass ❑ Fail ❑ Pass ❑ Fail <br />❑ Pass ❑ Faff <br />Comments — (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br />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: 9/14/2011 <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 />