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'... ti11W <br /> omsr <br /> oc e <br /> Spill Bucket Testing Report Form <br /> This form is intended far use by contractors performing annual testing of UST spill containment structures. The completed farm 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 I Date of Testing: 05/06/2008 <br /> Facility Address: 2500 W. Turner Road, Lodi CA 95242 <br /> Facility Contact: Leonard Freitas I Phone: (209) 367 2628 <br /> Date Local Agency Was Notified of Testing: 04/30/2008 <br /> Name of Local Agency Inspector(ifpresent during testing): Aris Cacapit <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: EPIC Compliance Systems, Inc. <br /> Technician Conducting Test: Nikola Zagorov <br /> Credentials': Rl CSLB Contractor 1CC Service Tech. SWRCB Tank Tester Other(Spec) <br /> License Number(s): 880430 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: 0 Hydrostatic Vacuum Other <br /> Test Equipment Used:Tape Measure Equipment Resolution:1/16 Inches <br /> Identify Spill Bucket(By lank Ij 1 Tank #1 -' 3 <br /> Number, Stored Product, etc)J1 Diesel <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: 12" <br /> Wait time between applying 10 min <br /> vacuum/water and start of test: <br /> Test Start Time(Ti): 9:00 AM <br /> Initial Reading(Rj): 107/8- <br /> Test <br /> 07/8"Test End Time(TF): 10:00 AM <br /> Final Reading(RF): 107/8- <br /> Test <br /> 07/8"Test Duration(TF—Tj): 1 Hour <br /> Change in Reading(RF-Rj): 0" <br /> Pass/Fail Threshold or 1/16" <br /> Criteria: <br /> Test Result: ©Pass 0 Fail ❑ Pass ❑Fail ❑ Pass 0 Fail 0 Pass Ll 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 alt the information contained in this report is true,accurate,and in full compliance with legal requirements. <br /> tr OlITechnician's Signature: N�fw Date: 05/06/2008 <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 />