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'TW V4W omur��C <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 Of applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Verizon-Lodi Date of Testing: 4/29/2011 <br /> Facility Address: 2500 W Turner, Lodi, CA 95242 <br /> Facility Contact: Jonathan Pakele Phone: 916-439-6042 <br /> Date Local Agency Was Notified of Testing: 4/21/2011 <br /> Name of Local Agency Inspector(i f present darning testing): M u nia ppa N81d u <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: EPIC Compliance Systems Inc. <br /> Technician Conducting Test: Al Milburn <br /> Credentials: 0 CSLB Contractor 0 ICC Service Tech. ❑ SWRCB Tank Tester ❑ Other(Specify) <br /> License Number(s): 956953 <br /> LL- <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Uscd: Q Hydrostatic ❑Vacuum ❑ Other <br /> Test Equipment Used: 1 hr Lake Test E ui ment Resolution: 1/16" <br /> Identify Spill Bucket (Bv Tank t 112 3 4 <br /> Number, Stored Product, etc.) Diesel <br /> 7777 <br /> Bucket Installation Type: 0 Direct Bury ❑Direct Bury ❑Direct Bury ❑ Direct Bury <br /> ❑Contained in Sump ❑Contained in Sump ❑Contained in Sump ❑Contained in Sump <br /> Bucket Diameter: 12" <br /> Bucket Depth: 13.75" <br /> Wait time between applying <br /> vacuum/water and start of test: 5 m i n <br /> Test Start Time(Ti): 1200 <br /> Initial Reading(R[): 11.25" <br /> Test End Time(TF): 1300 <br /> Final Reading(RF): 11.25" <br /> Test Duration (TF—T,): 1 hr <br /> Change in Reading(RF-R1): 0 <br /> Pass/Fail Threshold or 0 <br /> Criteria: <br /> Test Result: 0 Pass ❑Fail ❑ Pass ❑Fail ❑ Pass ❑ Fail © Pass ❑ Fail <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: g Date: 4/29/2011 <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 />