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ro <br /> �4C <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 (f 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: 05/06/2009 <br /> Facility Address: 2500 West Turner Road Lodi, CA 95242 <br /> Facility Contact: Gary Duvall T Phone: (209) 985-0843 <br /> Date Local Agency Was Notified of Testing: 04/28/2009 <br /> Name of Local Agency Inspector(ifpresent during testing): Ray Von Flue <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: EPIC Com liance Systems, Inc. <br /> Technician Conducting Test: Alvin L. Milburn <br /> Credentials': El CSLB Contractor ❑ [CC Service Tech. ❑ SWRCB Tank Tester ❑ Other(Spec) <br /> License Number(s): 880430 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: ❑X Hydrostatic ❑ Vacuum ❑ Other <br /> Test Equipment INed: 1 hour LAKE Test Equipment Resolution: <br /> Identify Spill Bucket(By Tank 1 Diesel 2 3 4 <br /> Number, Stored Product, etc.) <br /> Bucket Installation Type: [R]Direct Bury ❑ Direct Bury ❑Direct Bury ❑ Direct Bury <br /> ❑Contained in Sump ❑Contained in Sump ❑Contained in SuLnp ❑Contained in Sum <br /> Bucket Diameter: 12" <br /> Bucket Depth: 13 1/8" <br /> Wait time between applying 5 minutes <br /> vacuum/water and start of test: <br /> Test Start Time(T[): 12:43 PM <br /> Initial Reading(Ri): 11 3/4" <br /> Test End Time(TF): 1:43 PM <br /> Final Reading(RF): 11 3/4" <br /> Test Duration(TF—Tj): 1 hour <br /> Change in Reading(RF-Rj): 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 /> 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:. 05/06/2009 <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 />