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rP®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(f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: California Stop Date of Testing 3/13/2013 <br /> Facility Address: 2224 Manthey Road, Stockton, CA 95026 <br /> Facility Contact: Timmy Le Phone: 209-406-1484 <br /> Date Local Agency Was Notified of Testing: 2/21/2013 <br /> Name of Local Agency Inspector(if present during testing): Thuy Tran <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: EPIC Environmental Compliance Systems Inc. <br /> Technician Conducting Test:Al Milburn - <br /> Credentials': 0 CSLB Contractor 0 ICC Service Tech. ❑ SWRCB Tank Tester ❑Other(Spec) <br /> License Number(s): 956593 <br /> 3. SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: Q Hydrostatic ❑Vacuum ❑ Other <br /> Test Equipment Used: 1 hr Lake Test Equipment Resolution: 1/16" <br /> Identify Spill Bucket(By Tank 1 2 3 4 <br /> Number, Stored Product, etc. 87 91 Diesel <br /> Bucket Installation Type: 10 Direct Bury 2 Direct Bury Q Direct Bury ❑Direct Bury <br /> ❑Contained in Sump ❑Contained in Sump ❑Contained in Sump ❑Contained in Sum <br /> Bucket Diameter: 12" 12" 12" <br /> Bucket Depth: 14.5" 12.75" 11.5" <br /> Wait time between applying <br /> vacuum/water and start of test: 5 m i n 5 m i n 5 m i n <br /> Test Start Time(Tj): 1005 1005 1005 <br /> Initial Reading(R,): 13.25" 11.25" 10" <br /> Test End Time(TF): 1105 1105 1105 <br /> Final Reading(RF): 13.25" 11.25" 10" <br /> Test Duration(TF—TI): 1 hr 1 hr 1 hr <br /> Change in Reading(RF-RI): 0 0 0 <br /> Pass/Fail Threshold or 0 0 0 <br /> Criteria: <br /> Test Result: Q Pass ❑`Fail Q Pass ❑Fail QPass ❑Fail ❑Pass ❑Fail <br /> Comments—(include information on repairs made prior to testing, and recommended follow-up for failed tests) <br /> All Pass <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby certify that all the informationcontainedin this report is true,accurate,and in full compliance with legal requirements. <br /> Technician's Signature: �®` Date: 3/13/2013 <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 />