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Our <br /> Spill Bucket Testing Report Form m�¢ <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: Gas Depot Shell Date of Testing: 04/23/08 <br /> Facility Address: 824 E. Yosemite, Manteca, CA 95336 <br /> Facility Contact: John Phone: (209) 825-7722 <br /> Date Local Agency Was Notified of Testing: 04/26/08 <br /> Name of Local Agency Inspector(ifpresent during testing): Mon! <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: EPIC Compliance Systems, Inc. <br /> Technician Conducting Test: Alvin L. Milburn <br /> Credentials[ [Z CSLB Contractor ❑ICC Service Tech. - SWRCB Tank Tester ❑Other(Spec) <br /> License Number(s): 880430 <br /> 3. :SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: [H)Hydrostatic ❑Vacuum ❑Other <br /> Test Equipment Used: 1 Hour Lake Test Equipment Resolution: <br /> Identify Spill Bucket(By Tank 1 2 3 4 <br /> Number, Stored Product, etc.) 87 89 91 <br /> Bucket Installation Type: ❑x Direct Bury 0Direct Bury ❑X Direct Bury U Direct Bury <br /> ❑Contained in Sonia ❑Contained in Sump ❑Contained in Sump ❑Contained in Sump <br /> Bucket Diameter: 12 12 12 <br /> Bucket Depth: 14 14 14 <br /> Wait time between applying 5 min 5 min 5 min <br /> vacuum/water and start of test: <br /> Test Start Time(T,): 10:00 10:00 10:00 <br /> Initial Reading(R,): 13" 13" 11" <br /> Test End Time(TF): 11:00 11:00 11:00 <br /> Final Reading(RF): 13rr 13 if I I It <br /> Test Duration(TF—T,): 1 hr 1 hr 1 hr <br /> Change in Reading(RF-R,): 0 0 0 <br /> Pass/Fail Threshold or 0 0 0 <br /> Criteria: <br /> Test Result: HI Pass IJ Fail El Pass ❑ Fail O Pass ❑ Fail LJPass ❑ 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 info <br /> rmation contained i this report is true,accurate,and in full compliance with legal requirements. <br /> nfma <br /> Technician's Signature: �'" " Date: 04/23/08 <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 />