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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: Tracy Truck Stop JFDate of Testing: 03/26/2009 <br /> Facility Address: 3940 N. Tracy Blvd. Tracy CA 95304 <br /> Facility Contact: Debbie I Phone: (209) 832-5006 <br /> Date Local Agency Was Notified of Testing: 03/19/2009 <br /> Name of Local Agency Inspector(rfpresent during testing): Michelle Henry <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: EPIC Compliance Systems, Inc. <br /> Technician Conducting Test: Keith Huston <br /> Credentials': ®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 Hour LAKE Test Equipment Resolution: <br /> ✓F <br /> Identify Spill Bucket(By Tank 1 Premium 2 Regular 3 Diesel 4 Diesel <br /> Number,Stored Product, etc. <br /> Bucket Installation Type: 0 Direct Bury II Direct Bury 0 Direct Bury II Direct Bury <br /> ❑Contained in Sump ❑Contained in Sump ❑Contained in Sump ❑Contained in Sum <br /> Bucket Diameter: 12" 12" 12" 12" <br /> Bucket Depth: 14" 14" 14" 14" <br /> Wait time between applying 5 minutes 5 minutes 5 minutes 5 minutes <br /> vacuum/water and start of test: <br /> Test Start Time(T,): 10:50 AM 12:30 PM 10:50 AM 10:50 AM <br /> Initial Reading(Rj): 12 '/z" 12 15/16" 111/4" 12 1/4" <br /> Test End Time(TF): 11:50 AM 1:30 PM 11:50 AM 11:50 AM <br /> Final Reading(RF): 12 1/2" 12 15/16" 11 1/4" 12 1/4" <br /> Test Duration(TF—Tj): 1 hr. 1 hr. 1 hr. 1 hr. <br /> Change in Reading(RF-RI): 0 0 0 0 <br /> Pass/Fail Threshold or 1/16" hr. 1/16" hr. 1/16" hr. 1/16" hr. <br /> Criteria: <br /> Test Result:lt: 0 Pass UFail. ', EM Pass ❑Fail 0 Pass ,❑Fail 0 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 <br /> Date: 03/26/2009 <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 />