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cem <br />,mss <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: Verizon I Date of Testing: 09-13-2010 <br />Facility Address: 13850 Devries Road, Lodi, CA 95242 <br />Facility Contact: Jonathan Pakele I Phone: 209-235-3670 <br />Date Local Agency Was Notified of Testing: 09-09-2010 <br />Name of Local Agency Inspector (fpresent during testing): Aris Cacapit <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: EPIC Compliance Systems, Inc. <br />Technician Conducting Test: Al Milburn <br />Credentials: ❑ CSLB Contractor ❑ ICC Service Tech. ❑ SWRCB Tank Tester ❑ Other (Specify) <br />License Number(s): 90-1409 <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: <br />0 Hydrostatic <br />❑ Vacuum <br />❑ Other <br />Test Equipment Used: 1 hour Lake Test <br />Equipment Resolution: <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc. <br />1 <br />Diesel <br />2 <br />3 <br />4 <br />Bucket Installation Type: <br />❑ Direct Bury <br />0 Contained in Sump <br />❑ Direct Bury <br />❑ Contained in Sump <br />❑ Direct Bury <br />❑ Contained in Sump <br />❑ Direct Bury <br />❑ Contained in Sum <br />Bucket Diameter: <br />14" <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 (TI): <br />1500 <br />Initial Reading (Ri): <br />12.5" <br />Test End Time (TF): <br />1600 <br />Final Reading (RF): <br />12.5" <br />Test Duration (TF — Ti): <br />1 hr <br />Change in Reading (RF - RI): <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />0 <br />Test Result: <br />0 Pass ❑Fail <br />❑ Pass ❑ Fail <br />❑ Pass ❑ Fail <br />❑ Pass ❑ 'Fail <br />Comments —(include information on repairs made prior to testing, and recommended follow-up for failed tests) <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: <br />Date: 09-13-2010 <br />t 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 />