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Now ..e 0//F <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 Lodi I Date of Testing: 05/14/2010 <br /> Facility Address: 2500 West Turner Road, Lodi, CA, 95242 <br /> Facility Contact: Todd Harris Phone: 972-729-5671 <br /> Date Local Agency Was Notified of Testing : <br /> Name of Local Agency Inspector(ifpresent during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: EPIC Compliance Systems, Inc. <br /> Technician Conducting Test: Keith Huston <br /> Credentials: 0 CSLB Contractor ❑ ICC Service Tech. ❑ SWRCB Tank Tester ❑ Other(Specify) <br /> License Number(s): 880430 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: Rl Hydrostatic ❑ Vacuum ❑ Other <br /> Test Equipment Used: Equipment Resolution: <br /> Identify Spill Bucket (By Tank 1 2 3 4 <br /> Number, Stored Product, etc.) <br /> Bucket Installation Type: ❑ Direct Bury ❑ Direct Bury ❑Direct Bury ❑Direct Bury <br /> ❑Contained in Sump ❑ Contained in Sump ❑Contained in Sump ❑Contained in Sum <br /> Bucket Diameter: 12" <br /> Bucket Depth: 12" <br /> Wait time between applying 5min <br /> vacuum/water and start of test: <br /> Test Start Time(TE): 10:45 <br /> Initial Reading(Rj): 10 15/32" <br /> Test End Time(TF): 11:45 <br /> Final Reading(RF): 10 15/32" <br /> Test Duration(TF—Tj): 1 h r <br /> Change in Reading(RF-Rj): 0 <br /> Pass/Fail Threshold or 0 <br /> Criteria: <br /> Test Result: B Pass ❑Fail ❑ Pass ❑ Fail Ll Pass ❑ Fail ❑ 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 in/ormatIV contained in this report is true, accurate,and in full compliance with legal requirements. <br /> Technician's Signature: Date: 05/14/2010 <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 />