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0//// k <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(rf applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Charter Way Chevron Date of Testing: 10/22/08 <br /> Facility Address: 508 Charter Way, Stockton, CA 95206 <br /> Facility Contact: Marla I Phone: (209) 465-3440 <br /> Date Local Agency Was Notified of Testing: 09/30/08 <br /> Name of Local Agency Inspector(f present during testing): Ray Von Flue <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: EPIC Compliance Systems, Inc. <br /> Technician Conducting Test: Alvin L. Milburn <br /> Credentials' 10 CSLB Contractor - ICC Service Tech. - SWRCB Tank Tester -!Other(Sped) <br /> License Number(s): 880430 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: 0 Hydrostatic ❑Vacuum ❑ Other <br /> Test Equipment Used: 1 Hr. Lake Test Equipment Resolution: <br /> Identify Spill Bucket(By Tank 1 2 3 4 <br /> Number, Stored Product, etc) 87 91 Diesel <br /> Bucket Installation Type: 0 Direct Bury 0 Direct Bury 0 Direct Bury ❑Direct Bury <br /> ❑Contained in Sump ❑Contained in SuTp ❑Contained in Sum ❑Contained in Sump <br /> Bucket Diameter: 12" 12" 12" <br /> Bucket Depth: 13" 12.5" 13" <br /> Wait time between applying 5 min 5 min 5 min <br /> r <br /> ater and start of test: <br /> Time(T,): 12:20 12:20 12:20 <br /> ading(Rj): 11.5" 11.25" 11.5"Time(TF): 13:20 13:20 13:20 <br /> ding(RF): 11.5" 11.25" 11..5" <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: D Pass ❑ Fail 0 Pass ❑ Fail, 0 Pass ❑ Fait ❑Pass Ll.Fail <br /> Comments—(include information on repairs made prior to testing, and recommended follow-up for failed lasts) <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: 10/22/08 <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 />