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0 0 0////r <br /> �OC <br /> s„BEMs <br /> - <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(if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Teichert Equipment Date of Testing: 09/25/2009 <br /> Facility Address: 120 Frank West Circle Stockton CA 95206 <br /> Facility Contact: Steve Schauman Phone: 916-386-3767 <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(if present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: EPIC Compliance Systems, Inc. <br /> Technician Conducting Test: Keith Huston <br /> Credentials`: El 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: ❑Hydrostatic ❑ Vacuum ❑Other <br /> Test Equipment Used: Equipment Resolution: <br /> Identify Spill Bucket(By Tank 1 Diesel 2 Unleaded 3 Waste Oil 4 <br /> Number, Stored Product, etc. <br /> Bucket Installation Type: ❑Direct Bury ❑Direct Bury ❑Direct Bury ❑Direct Bury <br /> ❑x Contained in Sump IE Contained in Sump ❑x Contained in Sump ❑Contained in Sum <br /> Bucket Diameter: 12” 12" 12" <br /> Bucket Depth: 16" 16" 16" <br /> Wait time between applying 5 minutes 5 minutes 5 minutes <br /> vacuum/water and start of test: <br /> Test Start Time(TI): 10:30 AM 10:45 AM 01:45 PM <br /> Initial Reading(RI): 15 1/8" 14 7/8" 15" <br /> Test End Time(TF): 11:30 AM 11:45 AM 02:45 PM <br /> Final Reading(RF): 15 1/8" 14 7/8" 15" <br /> Test Duration(TF—T,): 1 hour 1 hour 1 hour <br /> Change in Reading(RF-RI): 0 0 0 <br /> Pass/Fail Threshold or 0 0 0 <br /> Criteria: <br /> Test Result: 0 Pass ®Fail ® Pass Ll Fail; C( Pass ❑Fait U Pass D 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: y `� Date: 09/25/2009 <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 />