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0 0 <br /> 0//r <br /> ��c <br /> t <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: Nicks Shell I Date of Testing: 11-21-08 <br /> Facility Address: 16500 Harland Lathrop, LA 95330 <br /> Facility Contact: Chris I Phone: 209-4033859 <br /> Date Local Agency Was Notified of Testing: 11-07-08 <br /> Name of Local Agency Inspector(fpresent during testing): Muniappa Naidu <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: EPIC Compliance Systems, Inc. <br /> Technician Conducting Test: Alvin L. Milburn <br /> Credentials' P 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: ❑x Hydrostatic ❑Vacuum ❑Other <br /> Test Equipment Used: 1 hr Lake Test Equipment Resolution: <br /> Identify Spill Bucket(By Tank 1 2 3 4 <br /> Number, Stored Product, etc) T1-91 T2-87 <br /> Bucket Installation Type: ❑x 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" 12" <br /> Bucket Depth: 13" 13" <br /> Wait time between applying <br /> vacuum/water and start of test: 5 m i n 5 m i n <br /> Test Start Time(TI): 3:05pm 3:15pm <br /> Initial Reading(R,): 12.5 12 <br /> Test End Time(TF): 4:05pm 4:15pm <br /> Final Reading(RF): 12.5 12 <br /> Test Duration(TF—TI): 1 h r 1 h r <br /> Change in Reading(RF-RI): 0 0 <br /> Pass/Fail Threshold or 0 0 <br /> Criteria: <br /> Test Result: D Pass ❑Fail QPass ❑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: 11/21/08 <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 />